=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306112073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEBRA HAVERSON PSYCHOTHERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 KINGS RD
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07940-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-476-4503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 SHADYLAWN DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07940-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-476-4503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. DEBRA A HAVERSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 973-476-4503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05474700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------