Provider Demographics
NPI:1295993475
Name:REID, MARY JO (LCSW)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:REID
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 1:18 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-4748
Mailing Address - Country:US
Mailing Address - Phone:973-895-5183
Mailing Address - Fax:
Practice Address - Street 1:170 CHANGEBRIDGE RD
Practice Address - Street 2:SUITE B 3-2
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9115
Practice Address - Country:US
Practice Address - Phone:973-895-5183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-24
Last Update Date:2008-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC003926001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical