=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821648965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALLY PITANGA LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2019
-----------------------------------------------------
Last Update Date | 03/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 VALLEY RD STE 1
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-259-5338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 VALLEY RD STE 1
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-259-5338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05881000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------