=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912373168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPY FOR DIVERSE FAMILIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2015
-----------------------------------------------------
Last Update Date | 08/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 PROSPECT AVE
-----------------------------------------------------
City | DUNELLEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08812-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-313-4611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 PROSPECT AVE
-----------------------------------------------------
City | DUNELLEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08812-1530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-313-4611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MICHELE NARDELLA
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 908-313-4611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 37F100175900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------