Provider Demographics
NPI:1194489161
Name:TABULA RASA PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:TABULA RASA PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIC. MARRIAGE & FAMILY THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CHARICE
Authorized Official - Last Name:SUMERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMFT
Authorized Official - Phone:973-637-0375
Mailing Address - Street 1:190 WILEY AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07062-1343
Mailing Address - Country:US
Mailing Address - Phone:973-637-0375
Mailing Address - Fax:
Practice Address - Street 1:190 WILEY AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07062-1343
Practice Address - Country:US
Practice Address - Phone:973-637-0375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health