Provider Demographics
NPI:1730756016
Name:MARDOSA, ALEXIS MEGAN (LPC, ATR-BC)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MEGAN
Last Name:MARDOSA
Suffix:
Gender:F
Credentials:LPC, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 STATE RT 284
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:NJ
Mailing Address - Zip Code:07461-3414
Mailing Address - Country:US
Mailing Address - Phone:973-294-6339
Mailing Address - Fax:
Practice Address - Street 1:113 STATE RT 284
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:NJ
Practice Address - Zip Code:07461-3414
Practice Address - Country:US
Practice Address - Phone:973-294-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00747600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37PC00747600OtherCOUNSELOR