Provider Demographics
NPI:1255928446
Name:MCINNIS, THERESA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LUPTON AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-5901
Mailing Address - Country:US
Mailing Address - Phone:856-693-5775
Mailing Address - Fax:
Practice Address - Street 1:1 LUPTON AVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-5901
Practice Address - Country:US
Practice Address - Phone:856-371-6804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06308700104100000X
NJ44SC060761001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1002431Medicaid