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General NPI Number Information
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NPI Number | 1699332221
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Entity Type | Individual
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Provider Name | SANTA GHOSH DASTIDAR LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/20/2019
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Last Update Date | 05/20/2019
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Provider Practice Location Address
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Address Line | 162 E RIDGEWOOD AVE STE 2
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City | RIDGEWOOD
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State | NJ
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Zip | 07450-3846
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Country | US
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Telephone | 201-373-6336
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Fax |
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Provider Business Mailing Address
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Address Line | 162 E RIDGEWOOD AVE STE 2
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City | RIDGEWOOD
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State | NJ
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Zip | 07450-3846
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Country | US
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Telephone | 201-373-6326
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC05780000
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License Number State | NJ
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