Provider Demographics
NPI:1679228944
Name:VANRYCK DEGROOT, CARINA VALENCIA
Entity Type:Individual
Prefix:
First Name:CARINA
Middle Name:VALENCIA
Last Name:VANRYCK DEGROOT
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 1:20 BEASLEY ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2901
Mailing Address - Country:US
Mailing Address - Phone:862-400-6175
Mailing Address - Fax:
Practice Address - Street 1:20 BEASLEY ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2901
Practice Address - Country:US
Practice Address - Phone:862-400-6175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1575544221106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician