=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932523883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAPA GANACHE PROJECT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2014
-----------------------------------------------------
Last Update Date | 02/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 MAIN ST
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-217-1750
-----------------------------------------------------
Fax | 732-217-1749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 MAIN ST
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-217-1750
-----------------------------------------------------
Fax | 732-217-1749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | MRS. LISA DALE SIROTI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 732-770-0428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------