=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154186757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NADINE ABDELAZIZ LAC, CCTP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2024
-----------------------------------------------------
Last Update Date | 02/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 N STATE RT 17 STE 100
-----------------------------------------------------
City | PARAMUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07652-2648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-978-9895
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 KENNEDY BLVD
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 551-554-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37AC00772300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------