Healthcare Provider Details

I. General information

NPI: 1699802074
Provider Name (Legal Business Name): VIVIAN JEAN DEETJEN BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

492 ROUTE 57 WEST FAMILY GUIDANCE CENTER OF WARREN COUNTY
WASHINGTON NJ
07882
US

IV. Provider business mailing address

3579 KNERR DRIVE
MACUNGIE PA
18062
US

V. Phone/Fax

Practice location:
  • Phone: 908-689-1000
  • Fax: 908-589-4529
Mailing address:
  • Phone: 908-454-5741
  • Fax: 908-213-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS-4121
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: