Provider Demographics
NPI:1619634144
Name:MISSONELLIE, NATHANIEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:
Last Name:MISSONELLIE
Suffix:
Gender:M
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:PO BOX 3431
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-0332
Mailing Address - Country:US
Mailing Address - Phone:973-271-5045
Mailing Address - Fax:
Practice Address - Street 1:80 BARCLAY SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2114
Practice Address - Country:US
Practice Address - Phone:973-271-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC057616001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical