Healthcare Provider Details

I. General information

NPI: 1467091124
Provider Name (Legal Business Name): ONLINEPSYCHDOC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 RIVER RD STE 32-158
EDGEWATER NJ
07020-1171
US

IV. Provider business mailing address

725 RIVER RD STE 32-158
EDGEWATER NJ
07020-1171
US

V. Phone/Fax

Practice location:
  • Phone: 201-255-4001
  • Fax:
Mailing address:
  • Phone: 201-255-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ELVIA VALENCIA
Title or Position: OWNER
Credential: PSYD
Phone: 201-255-4001