Provider Demographics
NPI:1417058892
Name:AZAVEDO, SIMON A (MSW LCSW CCBT DAPA)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:A
Last Name:AZAVEDO
Suffix:
Gender:M
Credentials:MSW LCSW CCBT DAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647
Mailing Address - Country:US
Mailing Address - Phone:201-261-8889
Mailing Address - Fax:
Practice Address - Street 1:222 KINDERKAMACK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649
Practice Address - Country:US
Practice Address - Phone:201-261-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051657001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
268673OtherMHN HEALTHNET
21225613301OtherBEECHSTREET
P2751253OtherOXFORD
268673OtherMHN HEALTHNET