Provider Demographics
NPI:1396247342
Name:MEDINO, ELISABETH MARY (LCSW)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:MARY
Last Name:MEDINO
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 1:38 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-2406
Mailing Address - Country:US
Mailing Address - Phone:973-907-4908
Mailing Address - Fax:
Practice Address - Street 1:38 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:POMPTON LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07442-2406
Practice Address - Country:US
Practice Address - Phone:973-907-4908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06073800104100000X
NJ44SC059635001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker