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General NPI Number Information
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NPI Number | 1225365372
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Entity Type | Organization
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Legal Business Name | MAPLE THERAPY CENTER LLC
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Dates
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Enumeration Date | 11/11/2009
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Last Update Date | 11/11/2009
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Provider Practice Location Address
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Address Line | 65 N MAPLE AVE # 209
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City | RIDGEWOOD
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State | NJ
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Zip | 07450-3233
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Country | US
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Telephone | 201-566-1535
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Fax |
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Provider Business Mailing Address
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Address Line | 65 N MAPLE AVE # 209
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City | RIDGEWOOD
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State | NJ
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Zip | 07450-3233
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Country | US
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Telephone | 201-566-1535
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | MS. SUSAN O PETERSON
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Credential | L.C.S.W.
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Telephone | 201-566-1535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC04898500
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License Number State | NJ
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