Provider Demographics
NPI:1306596093
Name:FUMOSA, MICHELLE LYNN (LCADC, ICADC, CCS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:FUMOSA
Suffix:
Gender:F
Credentials:LCADC, ICADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4261
Mailing Address - Country:US
Mailing Address - Phone:735-344-9239
Mailing Address - Fax:
Practice Address - Street 1:222 MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-4261
Practice Address - Country:US
Practice Address - Phone:973-534-4923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00311700101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)