Provider Demographics
NPI:1578260352
Name:OTTAVIANO, MICHELLE CHRISTINA (LSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CHRISTINA
Last Name:OTTAVIANO
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 1:201 HONEST JOHN ROAD
Mailing Address - Street 2:
Mailing Address - City:ESTELL MANOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08319
Mailing Address - Country:US
Mailing Address - Phone:856-649-2250
Mailing Address - Fax:
Practice Address - Street 1:201 HONEST JOHN ROAD
Practice Address - Street 2:
Practice Address - City:ESTELL MANOR
Practice Address - State:NJ
Practice Address - Zip Code:08319
Practice Address - Country:US
Practice Address - Phone:856-649-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL068356001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical