Provider Demographics
NPI:1356613079
Name:MICHAEL & LORI IPPOLITO
Entity type:Organization
Organization Name:MICHAEL & LORI IPPOLITO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:IPPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:973-667-6074
Mailing Address - Street 1:1 FRANKLIN AVE
Mailing Address - Street 2:PO BOX 599
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-0599
Mailing Address - Country:US
Mailing Address - Phone:973-667-6074
Mailing Address - Fax:
Practice Address - Street 1:567 FRANKLIN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1552
Practice Address - Country:US
Practice Address - Phone:973-667-6074
Practice Address - Fax:973-751-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty