Provider Demographics
NPI:1144477480
Name:MITA, WENDY ELLEN (LCSW)
Entity type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ELLEN
Last Name:MITA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:ELLEN
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:481 HACKENSACK AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6304
Mailing Address - Country:US
Mailing Address - Phone:201-488-6678
Mailing Address - Fax:201-488-6224
Practice Address - Street 1:11120 S CROWN WAY STE 1
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8718
Practice Address - Country:US
Practice Address - Phone:561-790-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC049319001041C0700X
FLSW116821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical