Provider Demographics
NPI:1740789866
Name:DBT OF SOUTH JERSEY, LLC
Entity Type:Organization
Organization Name:DBT OF SOUTH JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAELENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAURIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, NCC, LPC
Authorized Official - Phone:609-418-9141
Mailing Address - Street 1:309 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2034
Mailing Address - Country:US
Mailing Address - Phone:609-418-9141
Mailing Address - Fax:
Practice Address - Street 1:105 EVESBORO MEDFORD RD STE M
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3865
Practice Address - Country:US
Practice Address - Phone:609-353-5608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1770904112OtherNPPES