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General NPI Number Information
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NPI Number | 1962033357
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Entity Type | Individual
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Provider Name | ALEXANDRIA ELISSA SMALL LAC
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Gender | Female
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Dates
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Enumeration Date | 02/04/2020
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Last Update Date | 10/17/2025
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Provider Practice Location Address
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Address Line | 171 RIDGEDALE AVE STE J
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City | FLORHAM PARK
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State | NJ
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Zip | 07932-1764
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Country | US
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Telephone | 973-515-1216
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Fax | 973-515-3108
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Provider Business Mailing Address
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Address Line | 171 RIDGEDALE AVE STE J
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City | FLORHAM PARK
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State | NJ
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Zip | 07932-1764
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Country | US
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Telephone | 973-515-1216
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Fax | 973-515-3108
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 37AC00912600
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License Number State | NJ
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