Provider Demographics
NPI:1467754820
Name:PEGUERO SPENCER, CAROLYN (MA, LCSW)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:PEGUERO SPENCER
Suffix:
Gender:F
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BARNEGAT RD
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:NJ
Mailing Address - Zip Code:07421-3841
Mailing Address - Country:US
Mailing Address - Phone:973-647-4905
Mailing Address - Fax:
Practice Address - Street 1:1108 KINGS HWY STE 3A
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-3140
Practice Address - Country:US
Practice Address - Phone:973-647-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054264001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical