MEDICARE: MARIA ELENA PSYCHOLOGICAL

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	104100000X	Social Worker	44SL05809000	NJ

General Provider Information

NPI Number	:	1447656475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARIA ELENA PSYCHOLOGICAL

Provider Business Mailing Address
First Line	:	967 HAMBURG TPKE
Second Line	:
City	:	WAYNE
State	:	NJ
Zip	:	07470-3263
Country	:	US
Telephone Number	:	973-903-1109
Fax Number	:

Provider Business Practice Location Address
First Line	:	967 HAMBURG TPKE
Second Line	:
City	:	WAYNE
State	:	NJ
Zip	:	07470-3263
Country	:	US
Telephone Number	:	973-903-1109
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/OWNER
Name	:	MARIA ELENA MISITO-KLOSS
Credential	:	LCSW
Telephone Number	:	973-903-1109

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	11/19/2014

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