Provider Demographics
NPI:1962548560
Name:CHAN, JOSEPH A (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:A
Last Name:CHAN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2905
Mailing Address - Country:US
Mailing Address - Phone:973-202-1421
Mailing Address - Fax:973-707-7616
Practice Address - Street 1:85 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2905
Practice Address - Country:US
Practice Address - Phone:973-202-1421
Practice Address - Fax:973-707-7616
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051844001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ205791081OtherTAX IDENTIFICATION NUMBER