Provider Demographics
NPI:1275840332
Name:KITCHEN TABLE THERAPY, LLC
Entity Type:Organization
Organization Name:KITCHEN TABLE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MASON-REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-725-1807
Mailing Address - Street 1:31 NEWFIELD STREET
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07017-5410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 NEWFIELD STREET
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-5410
Practice Address - Country:US
Practice Address - Phone:201-725-1807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC00586800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty