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General NPI Number Information
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NPI Number | 1932929502
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Entity Type | Individual
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Provider Name | ELISSIA FORTY LSW
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Gender | Female
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Dates
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Enumeration Date | 10/16/2024
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 4551 ROUTE 42 STE 5
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City | BLACKWOOD
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State | NJ
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Zip | 08012-1751
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Country | US
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Telephone | 856-271-4490
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Fax |
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Provider Business Mailing Address
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Address Line | 455 PENN BLVD
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City | WOODBURY
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State | NJ
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Zip | 08096-2821
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Country | US
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Telephone | 856-271-4490
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 44SL06845000
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License Number State | NJ
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