Provider Demographics
NPI:1578132486
Name:CROAK, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CROAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E7 HILLSIDE CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07732-2016
Mailing Address - Country:US
Mailing Address - Phone:732-245-9801
Mailing Address - Fax:
Practice Address - Street 1:130 W WHITE HORSE PIKE STE 1B
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-2028
Practice Address - Country:US
Practice Address - Phone:856-352-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06615100101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health