Provider Demographics
NPI:1942381777
Name:MERCURIO, DANTE C (PHD)
Entity Type:Individual
Prefix:DR
First Name:DANTE
Middle Name:C
Last Name:MERCURIO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 BLOOMFIELD AVE
Mailing Address - Street 2:STE 14
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7129
Mailing Address - Country:US
Mailing Address - Phone:973-227-0642
Mailing Address - Fax:973-227-0675
Practice Address - Street 1:1099 BLOOMFIELD AVE
Practice Address - Street 2:STE 14
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7129
Practice Address - Country:US
Practice Address - Phone:973-227-0642
Practice Address - Fax:973-227-0675
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00344600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7191901Medicaid
NJS39194Medicare UPIN
NJ7191901Medicaid