=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821147513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DWANE RAZZETTI LSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 SICOMAC AVE
-----------------------------------------------------
City | WYCKOFF
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07481-2159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-848-5800
-----------------------------------------------------
Fax | 201-848-5493
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 W FAIRMOUNT AVE
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07607-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-843-7269
-----------------------------------------------------
Fax | 201-587-7506
-----------------------------------------------------
=====================================================
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 | 44SL04985000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------