Provider Demographics
NPI:1003515503
Name:DERIENZO, MARY T (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:DERIENZO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:
Other - Last Name:DERIENZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:818 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GARWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07027-1416
Mailing Address - Country:US
Mailing Address - Phone:908-670-7768
Mailing Address - Fax:
Practice Address - Street 1:818 CENTER ST
Practice Address - Street 2:
Practice Address - City:GARWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07027-1416
Practice Address - Country:US
Practice Address - Phone:908-670-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00071500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional