Provider Demographics
NPI:1598464968
Name:CERVANTES, MICHELLE (LSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CERVANTES
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 1:7430 KENNEDY BLVD APT 106
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4082
Mailing Address - Country:US
Mailing Address - Phone:929-426-3512
Mailing Address - Fax:
Practice Address - Street 1:444 60TH ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2200
Practice Address - Country:US
Practice Address - Phone:201-430-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06732500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker