Provider Demographics
NPI:1255016937
Name:PALACIO, EMMA JEAN
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:JEAN
Last Name:PALACIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MAIN ST STE 410
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5459
Mailing Address - Country:US
Mailing Address - Phone:908-499-4701
Mailing Address - Fax:
Practice Address - Street 1:80 MAIN ST STE 410
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5441
Practice Address - Country:US
Practice Address - Phone:856-772-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00724200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty