Provider Demographics
NPI:1649467242
Name:ROVELLO VISCO, MICHELE (LCP)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:ROVELLO VISCO
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1038
Mailing Address - Country:US
Mailing Address - Phone:908-230-4227
Mailing Address - Fax:908-464-8158
Practice Address - Street 1:121 NEWARK AVE STE 503
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-5873
Practice Address - Country:US
Practice Address - Phone:201-240-6186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00297400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional