Provider Demographics
NPI:1255752903
Name:BACK, ALIZA
Entity type:Individual
Prefix:
First Name:ALIZA
Middle Name:
Last Name:BACK
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 1:10 HEKEL RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5264
Mailing Address - Country:US
Mailing Address - Phone:516-567-7288
Mailing Address - Fax:
Practice Address - Street 1:10 HEKEL RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5264
Practice Address - Country:US
Practice Address - Phone:516-567-7288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-25
Last Update Date:2013-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05916600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker