Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 44SC05310100 | NJ |
NPI | 1003196023 |
---|---|
Provider Name | Lissa Captain |
First Address | Paterson, NJ 07503-2722 |
Second Address | Closter, NJ 07624-1912 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2011 |
Last Update Date | 23/02/2014 |