Provider Demographics
NPI:1902270788
Name:DOLE, BLANCA (CSW)
Entity Type:Individual
Prefix:
First Name:BLANCA
Middle Name:
Last Name:DOLE
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-1872
Mailing Address - Country:US
Mailing Address - Phone:973-289-4633
Mailing Address - Fax:201-653-0750
Practice Address - Street 1:1129 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-1872
Practice Address - Country:US
Practice Address - Phone:973-289-4633
Practice Address - Fax:201-653-0750
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SWO5328900104100000X
NJ18KT00609400173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No173C00000XOther Service ProvidersReflexologist