Provider Demographics
NPI:1962046433
Name:SURRATT, MARQUETTA S (MA, LAC)
Entity type:Individual
Prefix:
First Name:MARQUETTA
Middle Name:S
Last Name:SURRATT
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 DELSEA DR S
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2621
Mailing Address - Country:US
Mailing Address - Phone:856-725-9084
Mailing Address - Fax:856-881-5508
Practice Address - Street 1:42 DELSEA DR S
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-2621
Practice Address - Country:US
Practice Address - Phone:856-725-9084
Practice Address - Fax:856-881-5508
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00382900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional