Provider Demographics
NPI:1023360815
Name:ODRISCOLL, WINFRED (LSW)
Entity Type:Individual
Prefix:
First Name:WINFRED
Middle Name:
Last Name:ODRISCOLL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 RIVER RD STE 102A
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1172
Mailing Address - Country:US
Mailing Address - Phone:239-410-0988
Mailing Address - Fax:201-758-7573
Practice Address - Street 1:37 W CENTURY RD
Practice Address - Street 2:111
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1409
Practice Address - Country:US
Practice Address - Phone:201-262-2244
Practice Address - Fax:201-262-2246
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055601001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1023360815Medicaid