Provider Demographics
NPI:1083787584
Name:DORMONT, MITCHELL STEPHEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:STEPHEN
Last Name:DORMONT
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 1:495 TENNET ROAD
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3411
Mailing Address - Country:US
Mailing Address - Phone:732-446-4122
Mailing Address - Fax:
Practice Address - Street 1:1961 MORRIS AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5914
Practice Address - Country:US
Practice Address - Phone:908-686-0560
Practice Address - Fax:908-686-5040
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC004406001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
16598200OtherMERIT HMO
649435Medicare ID - Type Unspecified