Provider Demographics
NPI:1689213035
Name:MEREDITH, DIMITRIS MYLES (LPC)
Entity Type:Individual
Prefix:
First Name:DIMITRIS
Middle Name:MYLES
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 SANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1510
Mailing Address - Country:US
Mailing Address - Phone:717-343-7551
Mailing Address - Fax:
Practice Address - Street 1:12 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3211
Practice Address - Country:US
Practice Address - Phone:717-343-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00494400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional