Healthcare Provider Details

I. General information

NPI: 1528802568
Provider Name (Legal Business Name): PORTUM PRIVATE PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 ROUTE 31 S
ANNANDALE NJ
08801-3129
US

IV. Provider business mailing address

1465 ROUTE 31 S
ANNANDALE NJ
08801-3129
US

V. Phone/Fax

Practice location:
  • Phone: 732-614-0994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY DECKER
Title or Position: COO
Credential: MHA
Phone: 732-614-0994