Provider Demographics
NPI:1558443325
Name:KORMANN, PHYLLIS RUGLIO (LCSW)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:RUGLIO
Last Name:KORMANN
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 1:700 AIRPORT RD
Mailing Address - Street 2:P.O. BOX 2036
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5907
Mailing Address - Country:US
Mailing Address - Phone:732-367-4700
Mailing Address - Fax:732-364-2253
Practice Address - Street 1:1500 ROUTE 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2320
Practice Address - Country:US
Practice Address - Phone:732-785-1900
Practice Address - Fax:732-785-9500
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC003519001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
056541Medicare ID - Type Unspecified