Provider Demographics
NPI:1578391470
Name:SERULLE, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SERULLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 68TH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:GUTTENBERG
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3214
Mailing Address - Country:US
Mailing Address - Phone:732-832-1425
Mailing Address - Fax:
Practice Address - Street 1:433 PESHINE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2617
Practice Address - Country:US
Practice Address - Phone:973-705-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL067588001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical