Provider Demographics
NPI:1609540269
Name:MICK, COURTNEY C
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:C
Last Name:MICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 VALLEY RD UNIT 2636
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1319
Mailing Address - Country:US
Mailing Address - Phone:973-419-5261
Mailing Address - Fax:
Practice Address - Street 1:377 VALLEY RD UNIT 2636
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1319
Practice Address - Country:US
Practice Address - Phone:973-419-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06243200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker