Healthcare Provider Details

I. General information

NPI: 1083727622
Provider Name (Legal Business Name): THE NEW JERSEY INSTITUTE OF NEURBEHAVIOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 MARTINSVILLE RD RIVERWALK VILLAGE CENTER, SUITE 218
BASKING RIDGE NJ
07920-4700
US

IV. Provider business mailing address

665 MARTINSVILLE RD RIVERWALK VILLAGE CENTER, SUITE 218
BASKING RIDGE NJ
07920-4700
US

V. Phone/Fax

Practice location:
  • Phone: 908-604-1100
  • Fax: 908-607-1866
Mailing address:
  • Phone: 908-604-1100
  • Fax: 908-607-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1838
License Number StateNJ

VIII. Authorized Official

Name: DR. JAMES BRAGONIER GILLOCK
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: ED.D.
Phone: 908-604-1100