Provider Demographics
NPI:1386904944
Name:BAVOSI, CARISSA (LCSW)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:BAVOSI
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 1:905 ABBY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-6504
Mailing Address - Country:US
Mailing Address - Phone:908-692-6698
Mailing Address - Fax:
Practice Address - Street 1:905 ABBY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-6504
Practice Address - Country:US
Practice Address - Phone:908-692-6698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054936001041C0700X
NJ5633031041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool