Provider Demographics
NPI:1285368746
Name:MOMBRUN, GEORGES HENRY (LCSW, LCADC)
Entity type:Individual
Prefix:MR
First Name:GEORGES
Middle Name:HENRY
Last Name:MOMBRUN
Suffix:
Gender:M
Credentials:LCSW, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-1112
Mailing Address - Country:US
Mailing Address - Phone:973-592-9836
Mailing Address - Fax:
Practice Address - Street 1:560 MORRIS ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-1112
Practice Address - Country:US
Practice Address - Phone:973-592-9836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC059679001041C0700X
NJ37LC00326700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
093201OtherSELF-ISSUED