Healthcare Provider Details

I. General information

NPI: 1013155829
Provider Name (Legal Business Name): BENJAMIN JOHN CISROW IV LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W SUMMIT ST
VINELAND NJ
08360-2732
US

IV. Provider business mailing address

109 W SUMMIT ST
VINELAND NJ
08360-2732
US

V. Phone/Fax

Practice location:
  • Phone: 609-319-9536
  • Fax:
Mailing address:
  • Phone: 609-319-9536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL07257300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: