Provider Demographics
NPI:1760974257
Name:NUSSBAUM, IAN (LSW)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 ABERDARE CT UNIT 7
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-4918
Mailing Address - Country:US
Mailing Address - Phone:732-614-8034
Mailing Address - Fax:
Practice Address - Street 1:1500 SAINT GEORGES AVE STE E
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1000
Practice Address - Country:US
Practice Address - Phone:856-772-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06114300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker