=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548974520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRY TRACEY MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2023
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 TOWNSEND AVE
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08009-9011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-322-3270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 328 SPRUCE ST
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-780-7650
-----------------------------------------------------
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 | 44SC06420300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------