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General NPI Number Information
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NPI Number | 1902396104
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Entity Type | Organization
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Legal Business Name | TRAUMA-INFORMED PSYCHOTHERAPY, LLC
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Dates
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Enumeration Date | 05/14/2018
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 101 PARK ST # 3
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City | MONTCLAIR
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State | NJ
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Zip | 07042-2963
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Country | US
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Telephone | 973-447-4460
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Fax |
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Provider Business Mailing Address
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Address Line | 45 BAYLISS ST # 2
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City | NORTH ARLINGTON
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State | NJ
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Zip | 07031-5548
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Country | US
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Telephone | 201-377-8710
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARK WILLIAM RICHARDSON
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Credential | LCSW
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Telephone | 201-377-8710
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC05682000
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License Number State | NJ
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