Basic Information
Provider Information
NPI: 1639641210
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FROST
FirstName: SETH
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.ED., LAC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2 DELSEA DR. S.
Address2:  
City: GLASSBORO
State: NJ
PostalCode: 08028
CountryCode: US
TelephoneNumber: 8568818689
FaxNumber:  
Practice Location
Address1: 2 DELSEA DR S.
Address2:  
City: GLASSBORO
State: NJ
PostalCode: 08028
CountryCode: US
TelephoneNumber: 8568818689
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/20/2018
LastUpdateDate: 12/20/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101Y00000X  Y193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselor 

No ID Information.


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