Provider Demographics
NPI:1942708102
Name:RAJA SALLOUM
Entity Type:Organization
Organization Name:RAJA SALLOUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YASMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EISSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-424-1687
Mailing Address - Street 1:48 GREENLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3212
Mailing Address - Country:US
Mailing Address - Phone:201-887-6678
Mailing Address - Fax:
Practice Address - Street 1:45 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3439
Practice Address - Country:US
Practice Address - Phone:201-887-6678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC0545510001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty