Provider Demographics
NPI:1700029477
Name:KOURGELIS, DEBORAH R (LCSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:R
Last Name:KOURGELIS
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 1:115 FRANKLIN TPKE # 198
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1325
Mailing Address - Country:US
Mailing Address - Phone:201-529-3531
Mailing Address - Fax:
Practice Address - Street 1:163 DAYTON ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4407
Practice Address - Country:US
Practice Address - Phone:201-694-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053004001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical