MEDICARE: MY THERAPIST LLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1396414181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY THERAPIST LLC

Provider Business Mailing Address
First Line	:	1541 10TH AVE
Second Line	:
City	:	TOMS RIVER
State	:	NJ
Zip	:	08757-2839
Country	:	US
Telephone Number	:	732-510-3641
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 N COUNTY LINE RD STE 16
Second Line	:
City	:	JACKSON
State	:	NJ
Zip	:	08527-1466
Country	:	US
Telephone Number	:	732-510-3641
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KAYLA DUKESS
Credential	:
Telephone Number	:	732-510-3641

Provider Enumeration Date	:	09/07/2021
Last Update Date	:	09/07/2021

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Directions to “MY THERAPIST LLC ” Practice Location

Language	Start Address	Practice Location

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