Provider Demographics
NPI:1619029261
Name:NOWAK, LAURA JEAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JEAN
Last Name:NOWAK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 EAST SHORE CULVER ROAD
Mailing Address - Street 2:
Mailing Address - City:BRANCHVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07826
Mailing Address - Country:US
Mailing Address - Phone:973-948-0889
Mailing Address - Fax:
Practice Address - Street 1:130 POWERVILLE ROAD
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005
Practice Address - Country:US
Practice Address - Phone:973-316-1926
Practice Address - Fax:973-299-5466
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC04635500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
053011Medicare ID - Type Unspecified