Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | SCO8663 | NJ |
N | 103T00000X | Psychologist | SCO8663 | NJ |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | SCO8663 | NJ |
N | 103TA0700X | Adult Development & Aging Psychologist | SCO8663 | NJ |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | SCO8663 | NJ |
N | 103TF0000X | Family Psychologist | SCO8663 | NJ |
N | 103TP2701X | Group Psychotherapist | SCO8663 | NJ |
N | 103TR0400X | Rehabilitation Psychologist | SCO8663 | NJ |
Y | 104100000X | Social Worker | SCO8663 | NJ |
NPI | 1700917820 |
---|---|
Provider Name | Ms. Agnes Raeven |
First Address | Sparta, NJ 07871-2410 |
Second Address | Sparta, NJ 07871-2410 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2007 |
Last Update Date | 09/10/2013 |