=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790931269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELDEROLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2008
-----------------------------------------------------
Last Update Date | 08/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 CARSAM ST
-----------------------------------------------------
City | FANWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07023-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-889-0714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 CARSAM ST
-----------------------------------------------------
City | FANWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07023-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-889-0714
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | CYNTHIA ANN PUCHAMMER
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 908-889-0714
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 44SC05307500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------