Provider Demographics
NPI:1588434302
Name:GERCKENS, MEREDITH JEAN (LAC)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:JEAN
Last Name:GERCKENS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 SHACKAMAXON DRIVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-3405
Mailing Address - Country:US
Mailing Address - Phone:908-403-1512
Mailing Address - Fax:
Practice Address - Street 1:637 SHACKAMAXON DRIVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-3405
Practice Address - Country:US
Practice Address - Phone:908-403-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00750400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty