Basic Information
| Provider Information | |||||||||
| NPI: | 1114178977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JANINE MARIS LCSW, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078220658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733004110 | ||||||||
| FaxNumber: | 9735799007 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 MAIN ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NEWTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078602056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733004110 | ||||||||
| FaxNumber: | 9735799007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2008 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARIS | ||||||||
| AuthorizedOfficialFirstName: | JANINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9733004110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 44SC05214800 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 44SC05214800 | 01 | NJ | STATE LICENSE | OTHER |