Provider Demographics
NPI:1790215069
Name:FACENDO, COURTNEY (LSW)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:FACENDO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 CROOKED STICK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4032
Mailing Address - Country:US
Mailing Address - Phone:848-218-0790
Mailing Address - Fax:732-358-0829
Practice Address - Street 1:1466 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-2892
Practice Address - Country:US
Practice Address - Phone:848-218-0790
Practice Address - Fax:732-358-0829
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06213900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health