Provider Demographics
NPI:1073029138
Name:BOSTIC, MONIQUE VAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:VAN
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 S ORANGE AVE # 518
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-1342
Mailing Address - Country:US
Mailing Address - Phone:973-910-0518
Mailing Address - Fax:844-971-1968
Practice Address - Street 1:25 POMPTON AVE STE 304
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-2939
Practice Address - Country:US
Practice Address - Phone:973-910-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05554900104100000X, 1041C0700X
GACSW0070951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker