=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285412098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY FRANCES ANGELA PRUGNO MSED, LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2023
-----------------------------------------------------
Last Update Date | 12/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2006 HIGHWAY NJ-71 SUITE 4
-----------------------------------------------------
City | SPRING LAKE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-919-1335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 DUBAC RD
-----------------------------------------------------
City | WALL TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07719-3772
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 37AC00748100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------