Provider Demographics
NPI:1124640677
Name:PEGUERO, ELAINE (LCADC)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:PEGUERO
Suffix:
Gender:F
Credentials:LCADC
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:
Other - Last Name:PEGUERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:271 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-1707
Mailing Address - Country:US
Mailing Address - Phone:201-560-6389
Mailing Address - Fax:
Practice Address - Street 1:795 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4812
Practice Address - Country:US
Practice Address - Phone:201-488-5161
Practice Address - Fax:201-488-5162
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00314900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)