Provider Demographics
NPI:1003352303
Name:DERDZIKOWSKI, ASHLEY (LAC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:DERDZIKOWSKI
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 1:600 PAVONIA AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306
Mailing Address - Country:US
Mailing Address - Phone:732-228-8060
Mailing Address - Fax:201-222-7676
Practice Address - Street 1:600 PAVONIA AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:732-228-8060
Practice Address - Fax:201-222-7676
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00259500101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor