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General NPI Number Information
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NPI Number | 1578370706
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Entity Type | Individual
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Provider Name | ELYSSA MARTINO MA
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Gender | Female
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Dates
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Enumeration Date | 12/11/2024
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Last Update Date | 12/11/2024
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Provider Practice Location Address
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Address Line | 96 CHADWICK ST
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City | EAST RUTHERFORD
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State | NJ
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Zip | 07073-1603
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Country | US
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Telephone | 201-414-1568
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Fax |
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Provider Business Mailing Address
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Address Line | 96 CHADWICK ST
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City | EAST RUTHERFORD
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State | NJ
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Zip | 07073-1603
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Country | US
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Telephone | 201-414-1568
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | BACB765732
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License Number State | NJ
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