=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962939322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELISSA A KLEIWERDA LCSW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2017
-----------------------------------------------------
Last Update Date | 05/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 753 BERGEN BLVD LOWR LEVEL
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07657-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-570-5923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 753 BERGEN BLVD LOWER LEVEL
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MELISSA A KLEIWERDA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 973-570-5923
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05437000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------