=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114496825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARI GOTTLIEB KORNFIELD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2018
-----------------------------------------------------
Last Update Date | 05/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 HOPE ROAD, BLDG 3B, MAILBOX #8
-----------------------------------------------------
City | EATONTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07724-0772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-724-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 HOPE ROAD, BLDG 3B, MAILBOX #8
-----------------------------------------------------
City | EATONTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-724-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05826900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------