Provider Demographics
NPI:1043727662
Name:RAITZIK, CHANANYA B (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHANANYA
Middle Name:B
Last Name:RAITZIK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SHAYAS RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5564
Mailing Address - Country:US
Mailing Address - Phone:732-363-8650
Mailing Address - Fax:
Practice Address - Street 1:19 SHAYAS RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5564
Practice Address - Country:US
Practice Address - Phone:732-363-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093485-1104100000X
NJ44SC057423001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker