=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649836917
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANINE LEIGH ILSLEY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2019
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 CLAREMONT AVE STE 5
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-2218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-506-8184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 51 JAMES ST APT 3E
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-2933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-397-2003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 105694
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 094537
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------