=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104630425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEYSA ETIENNE LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2025
-----------------------------------------------------
Last Update Date | 02/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 FISHERS LN
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07871-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-726-4533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 WHARTON AVE
-----------------------------------------------------
City | MINE HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07803-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-767-4334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 37F100239500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------