=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043168966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER IMAGE COUNSELING & CONSULTING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2026
-----------------------------------------------------
Last Update Date | 03/17/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2115 MILLBURN AVE
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-620-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2115 MILLBURN AVE
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-3724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-620-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CAROLYN DAVIS-COTTLE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 866-620-2323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------