Provider Demographics
NPI:1568819621
Name:SAN GIACOMO, ASHLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SAN GIACOMO
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 1:42 MARLEY AVE
Mailing Address - Street 2:1
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1139
Mailing Address - Country:US
Mailing Address - Phone:973-903-1613
Mailing Address - Fax:
Practice Address - Street 1:42 MARLEY AVE
Practice Address - Street 2:1
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1139
Practice Address - Country:US
Practice Address - Phone:973-903-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SLO5793600104100000X
NJ8569881041S0200X
NJ44SC057006001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0519120Medicaid