Basic Information
| Provider Information | |||||||||
| NPI: | 1003243817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HATAMI | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AFFA | ||||||||
| OtherFirstName: | SUSAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 JUMPING BROOK RD | ||||||||
| Address2: | BLDG 5, STE 201, ATTN: BEHAVIORAL HEALTH CREDENTIALING | ||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326434372 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1011 BOND ST | ||||||||
| Address2: | |||||||||
| City: | ASBURY PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077125939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328692769 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2013 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 44SC05759800 | NJ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.