Provider Demographics
NPI:1063241248
Name:SHAFFER, CARLY (LSW, LCADC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:LSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 KIRKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GIBBSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08026-1418
Mailing Address - Country:US
Mailing Address - Phone:856-834-4469
Mailing Address - Fax:
Practice Address - Street 1:221 RIVER STREET
Practice Address - Street 2:9TH FLOOR
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030
Practice Address - Country:US
Practice Address - Phone:646-941-7645
Practice Address - Fax:929-596-7897
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06815000101YM0800X
NJ37LC00385700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health