Provider Demographics
NPI:1144328931
Name:VICARISI JR, BENEDICT JR (EDS)
Entity type:Individual
Prefix:MR
First Name:BENEDICT
Middle Name:
Last Name:VICARISI JR
Suffix:JR
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 HAZEL AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4524
Mailing Address - Country:US
Mailing Address - Phone:973-495-1818
Mailing Address - Fax:
Practice Address - Street 1:395 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2905
Practice Address - Country:US
Practice Address - Phone:973-495-1818
Practice Address - Fax:973-495-1818
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPC01046101YP2500X
NJFI0014959106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ232752OtherHEALTH NET MANAGED CARE
NJ490655000OtherMAGELLAN BLUE CROSS
NJP2728931OtherOXFORD