MEDICARE: LISA FEDERICO 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	37LC00276800	NJ

General Provider Information

NPI Number	:	1710461264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA FEDERICO LCADC

Provider Business Mailing Address
First Line	:	300 LAFAYETTE ST APT 2
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-2120
Country	:	US
Telephone Number	:	732-610-7703
Fax Number	:

Provider Business Practice Location Address
First Line	:	551 PARK AVE STE 7
Second Line	:
City	:	SCOTCH PLAINS
State	:	NJ
Zip	:	07076-1768
Country	:	US
Telephone Number	:	732-610-7703
Fax Number	:

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

Provider Enumeration Date	:	09/20/2018
Last Update Date	:	09/20/2018

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