Provider Demographics
NPI:1467050641
Name:MIRLIS, JILL (PSYD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MIRLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:BOGARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:122 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4753
Mailing Address - Country:US
Mailing Address - Phone:973-930-1770
Mailing Address - Fax:
Practice Address - Street 1:122 HIGH ST
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4753
Practice Address - Country:US
Practice Address - Phone:973-930-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026273103T00000X
NJ35S100704700103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist