Provider Demographics
NPI:1710740659
Name:FASTOW, LAUREL RHONA
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:RHONA
Last Name:FASTOW
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 1:76 S ORANGE AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1923
Mailing Address - Country:US
Mailing Address - Phone:973-704-4657
Mailing Address - Fax:
Practice Address - Street 1:76 S ORANGE AVE STE 214
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1923
Practice Address - Country:US
Practice Address - Phone:973-704-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC005970001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical