Provider Demographics
NPI:1609921998
Name:CENTENO, LINDA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:CENTENO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PINE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-1619
Mailing Address - Country:US
Mailing Address - Phone:201-925-9700
Mailing Address - Fax:201-670-1214
Practice Address - Street 1:115 PINE ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-1619
Practice Address - Country:US
Practice Address - Phone:201-925-9700
Practice Address - Fax:201-670-1214
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ069220Medicare ID - Type Unspecified