Healthcare Provider Details

I. General information

NPI: 1316445810
Provider Name (Legal Business Name): BUSTER KLAY DWEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2018
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 OLD YORK RD
BORDENTOWN NJ
08505-2925
US

IV. Provider business mailing address

120 ELM ST APT AP1
BEVERLY NJ
08010-2549
US

V. Phone/Fax

Practice location:
  • Phone: 609-324-0296
  • Fax:
Mailing address:
  • Phone: 609-372-8199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: