Provider Demographics
NPI:1487009452
Name:INNER IMAGE COUNSELING & CONSULTING SERVICES
Entity Type:Organization
Organization Name:INNER IMAGE COUNSELING & CONSULTING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS-COTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:1866-620-2323
Mailing Address - Street 1:2130 MILLBURN AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3725
Mailing Address - Country:US
Mailing Address - Phone:186-662-0232
Mailing Address - Fax:
Practice Address - Street 1:90 VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5833
Practice Address - Country:US
Practice Address - Phone:186-662-0232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05642500251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health