Provider Demographics
NPI:1962487801
Name:TATLOCK, MOLLY (LCSW)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:TATLOCK
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 1:59 HART AVE
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08525-1411
Mailing Address - Country:US
Mailing Address - Phone:609-466-7807
Mailing Address - Fax:
Practice Address - Street 1:492 ROUTE 57 W
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-4338
Practice Address - Country:US
Practice Address - Phone:908-689-1000
Practice Address - Fax:908-689-4529
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC007551001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ642854Medicare ID - Type Unspecified