=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770031114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILMORE ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2016
-----------------------------------------------------
Last Update Date | 12/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 FRANKLIN AVE SUITE 202
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-667-6074
-----------------------------------------------------
Fax | 973-751-1626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | ONE FRANKLIN AVENUE PO BOX 599
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-0599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-667-6074
-----------------------------------------------------
Fax | 973-751-1626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LORI R IPPOLITO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 973-667-6074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC00042000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------