Provider Demographics
NPI:1013218528
Name:SACRISTAN, DOLLY R (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:DOLLY
Middle Name:R
Last Name:SACRISTAN
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-2229
Mailing Address - Country:US
Mailing Address - Phone:201-776-4004
Mailing Address - Fax:212-960-0821
Practice Address - Street 1:113 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2229
Practice Address - Country:US
Practice Address - Phone:201-776-4004
Practice Address - Fax:212-960-0821
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054396001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical