=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891455705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHENA MARESCOT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2021
-----------------------------------------------------
Last Update Date | 12/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7612 PARK AVE APT A3
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-5585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-522-1641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7612 PARK AVE APT A3
-----------------------------------------------------
City | NORTH BERGEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07047-5585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 120-352-2164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 114908
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------