Provider Demographics
NPI:1720535511
Name:CERTOSIMO, MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CERTOSIMO
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 1:130 S MAHWAH RD
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1859
Mailing Address - Country:US
Mailing Address - Phone:201-739-6489
Mailing Address - Fax:
Practice Address - Street 1:400D LAKE ST STE 2
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1279
Practice Address - Country:US
Practice Address - Phone:201-739-6489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC058532001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical