=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750891248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIA ELANA CARDILLO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2017
-----------------------------------------------------
Last Update Date | 11/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 CAMELOT PL LOT OFFICE
-----------------------------------------------------
City | SEWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08080-2308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-981-5045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8739
-----------------------------------------------------
City | BLACKWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08012-8739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-617-3552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARIA ELANA CARDILLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-617-3552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------