Provider Demographics
NPI:1952373029
Name:IMMERMAN, DAVID (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:IMMERMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-3957
Mailing Address - Country:US
Mailing Address - Phone:609-396-6788
Mailing Address - Fax:
Practice Address - Street 1:2550 BRUNSWICK PIKE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4103
Practice Address - Country:US
Practice Address - Phone:609-396-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000363001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS25597Medicare UPIN
NJ887270Medicare ID - Type Unspecified