Provider Demographics
NPI:1306587746
Name:SACK-JOHNSON, DOROTHY WINIFRED
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:WINIFRED
Last Name:SACK-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 E RIDGEWOOD AVE STE 4&4A
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3935
Mailing Address - Country:US
Mailing Address - Phone:201-670-8443
Mailing Address - Fax:
Practice Address - Street 1:1156 E RIDGEWOOD AVE STE 4&4A
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3935
Practice Address - Country:US
Practice Address - Phone:201-670-8443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPC-01298101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPC-01298OtherNJ LICENSE NUMBER