Provider Demographics
NPI:1194379156
Name:PATRISSO, MINDY ROBIN
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:ROBIN
Last Name:PATRISSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 ANNIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-6811
Mailing Address - Country:US
Mailing Address - Phone:973-494-4068
Mailing Address - Fax:
Practice Address - Street 1:12 SMULL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5012
Practice Address - Country:US
Practice Address - Phone:973-494-4068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC049451001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ060300OtherPRIVATE CLIENTS