Provider Demographics
NPI:1982891933
Name:BUSUTTIL, GRACE COPPOLA (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:COPPOLA
Last Name:BUSUTTIL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2643
Mailing Address - Country:US
Mailing Address - Phone:201-615-6947
Mailing Address - Fax:
Practice Address - Street 1:380 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2643
Practice Address - Country:US
Practice Address - Phone:201-615-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC046201001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ096090Medicare PIN