=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972192102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPROUTING SOLUTIONS PSYCHOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 US HIGHWAY 22
-----------------------------------------------------
City | GREEN BROOK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08812-1808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-631-4297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 US HIGHWAY 22
-----------------------------------------------------
City | GREEN BROOK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08812-1808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-631-4297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MS. SHENELLE SRIWARDENA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 732-631-4297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------