Healthcare Provider Details

I. General information

NPI: 1417618893
Provider Name (Legal Business Name): PRIMARY MDPSYCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 LEGACY LN APT 203
PALM BEACH GARDENS FL
33410-3612
US

IV. Provider business mailing address

55 BONNIE DR
MANALAPAN NJ
07726-1858
US

V. Phone/Fax

Practice location:
  • Phone: 561-420-6419
  • Fax:
Mailing address:
  • Phone: 561-420-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIRYAM ARJONA
Title or Position: OWNER
Credential: LCSW
Phone: 561-420-6419