Provider Demographics
NPI:1457699621
Name:BAK, ELIYAHU DOVID (LSW)
Entity type:Individual
Prefix:
First Name:ELIYAHU
Middle Name:DOVID
Last Name:BAK
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1254
Practice Address - Country:US
Practice Address - Phone:908-783-7978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05716900104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker