Provider Demographics
NPI:1568161388
Name:VIETZE, REBECCA SIMONE (LSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SIMONE
Last Name:VIETZE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WALNUT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1647
Mailing Address - Country:US
Mailing Address - Phone:732-605-6029
Mailing Address - Fax:
Practice Address - Street 1:60 WALNUT AVE STE 200
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1647
Practice Address - Country:US
Practice Address - Phone:732-605-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL6879600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor