Provider Demographics
NPI:1619030269
Name:LIDESTRI, CHRISTINE J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:J
Last Name:LIDESTRI
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 1:121 WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-1014
Mailing Address - Country:US
Mailing Address - Phone:201-385-2296
Mailing Address - Fax:
Practice Address - Street 1:100 HOLLISTER RD UNIT 7
Practice Address - Street 2:
Practice Address - City:TETERBORO
Practice Address - State:NJ
Practice Address - Zip Code:07608-1139
Practice Address - Country:US
Practice Address - Phone:201-498-9140
Practice Address - Fax:201-498-9144
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC008347001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ441835C2RMedicare ID - Type Unspecified