MEDICARE: LIBERTY CHILD AND ADOLESCENT HEALTH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003812728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY CHILD AND ADOLESCENT HEALTH SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 334
Second Line	:
City	:	WAYNE
State	:	NJ
Zip	:	07474-0334
Country	:	US
Telephone Number	:	201-804-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 NEWARK AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-1326
Country	:	US
Telephone Number	:	201-714-7902
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD J BONFORTE
Credential	:	MD
Telephone Number	:	201-714-7903

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	08/22/2020

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