Provider Demographics
NPI:1366157174
Name:NUSSBAUM, KEVIN (LSW)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:MR
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:NUSBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LSW
Mailing Address - Street 1:2117 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08757-3610
Mailing Address - Country:US
Mailing Address - Phone:908-783-8778
Mailing Address - Fax:
Practice Address - Street 1:2117 3RD AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08757-3610
Practice Address - Country:US
Practice Address - Phone:908-783-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05153000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker