Healthcare Provider Details

I. General information

NPI: 1578779625
Provider Name (Legal Business Name): VICTORIA MARIE CARRELLE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 WOOD RIDGE ST
WOOD RIDGE NJ
07075-2416
US

IV. Provider business mailing address

51 WOOD RIDGE ST
WOOD RIDGE NJ
07075-2416
US

V. Phone/Fax

Practice location:
  • Phone: 201-460-8774
  • Fax:
Mailing address:
  • Phone: 201-460-8774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00355200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: