Provider Demographics
NPI:1902496532
Name:NUSSBAUM, TAMMY (MASTERS IN SCIENCE)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:MASTERS IN SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 BROAD ST STE 6
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2884
Mailing Address - Country:US
Mailing Address - Phone:862-930-5700
Mailing Address - Fax:973-707-2383
Practice Address - Street 1:1018 BROAD ST STE 6
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2884
Practice Address - Country:US
Practice Address - Phone:862-930-5700
Practice Address - Fax:973-707-2383
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00155200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37LC0015520OtherLCADC