Provider Demographics
NPI:1508239898
Name:BLUE, CHANTA (LCSW)
Entity Type:Individual
Prefix:
First Name:CHANTA
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UPPER MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-1871
Mailing Address - Country:US
Mailing Address - Phone:201-463-5084
Mailing Address - Fax:
Practice Address - Street 1:1 UPPER MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-1871
Practice Address - Country:US
Practice Address - Phone:201-463-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5873361041S0200X
NJ44SC057034001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool