Healthcare Provider Details

I. General information

NPI: 1629221239
Provider Name (Legal Business Name): KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 EVERGREEN PL SUITE 500
EAST ORANGE NJ
07018-2106
US

IV. Provider business mailing address

60 EVERGREEN PL SUITE 500
EAST ORANGE NJ
07018-2106
US

V. Phone/Fax

Practice location:
  • Phone: 973-672-6900
  • Fax: 866-376-8262
Mailing address:
  • Phone: 973-672-6900
  • Fax: 866-376-8262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number37LC00040000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number26NR13660400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC004779
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00330900
License Number StateNJ

VIII. Authorized Official

Name: MR. DANIEL CASSELL
Title or Position: EXECUTIVE DIRECTOR/PRESIDENT
Credential: MA, MPH, LPC, LCADC
Phone: 973-672-6900