Provider Demographics
NPI:1306502950
Name:IHEAKARAM, CHINNA KRYSTAL (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHINNA
Middle Name:KRYSTAL
Last Name:IHEAKARAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S KEY ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3507
Mailing Address - Country:US
Mailing Address - Phone:973-207-4698
Mailing Address - Fax:
Practice Address - Street 1:11 S KEY ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3507
Practice Address - Country:US
Practice Address - Phone:973-207-4698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05812600104100000X
NJ44SC064211001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker