Provider Demographics
NPI:1083668958
Name:HERMANN, SALLY L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:L
Last Name:HERMANN
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 1:2219 E BAY TER
Mailing Address - Street 2:
Mailing Address - City:SHIP BOTTOM
Mailing Address - State:NJ
Mailing Address - Zip Code:08008-4342
Mailing Address - Country:US
Mailing Address - Phone:609-361-1934
Mailing Address - Fax:609-361-1934
Practice Address - Street 1:620 LACEY RD
Practice Address - Street 2:SUITE 5
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2244
Practice Address - Country:US
Practice Address - Phone:609-312-6453
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC00444200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ661392Medicare ID - Type Unspecified