MEDICARE: VINCENT G DENOTARIS LCADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00190000	NJ

General Provider Information

NPI Number	:	1154799815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCENT G DENOTARIS LCADC

Provider Business Mailing Address
First Line	:	25 POMPTON AVE
Second Line	:	SUITE 311
City	:	VERONA
State	:	NJ
Zip	:	07044-2941
Country	:	US
Telephone Number	:	973-534-9276
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 POMPTON AVE
Second Line	:	SUITE 311
City	:	VERONA
State	:	NJ
Zip	:	07044-2941
Country	:	US
Telephone Number	:	973-534-9276
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	01/23/2017

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