Healthcare Provider Details

I. General information

NPI: 1306697255
Provider Name (Legal Business Name): DIANE BLEIMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 ROUTE 35
WALL TOWNSHIP NJ
07719-3530
US

IV. Provider business mailing address

1212 TODD CT
LAKEWOOD NJ
08701-2256
US

V. Phone/Fax

Practice location:
  • Phone: 732-481-4743
  • Fax:
Mailing address:
  • Phone: 609-225-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00066500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SL04965700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: