Healthcare Provider Details

I. General information

NPI: 1952654972
Provider Name (Legal Business Name): ERIDIAN BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOND ST
ASBURY PARK NJ
07712-5939
US

IV. Provider business mailing address

1011 BOND ST
ASBURY PARK NJ
07712-5939
US

V. Phone/Fax

Practice location:
  • Phone: 732-859-1794
  • Fax:
Mailing address:
  • Phone: 732-859-1794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number37LC00188000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number44SC05427900
License Number StateNJ

VIII. Authorized Official

Name: MR. PETER E DOUGHERTY
Title or Position: CLINICAL SUPERVISOR
Credential: LCSW, LCADC
Phone: 732-869-2773