Healthcare Provider Details

I. General information

NPI: 1275777195
Provider Name (Legal Business Name): MIGUEL OQUENDO MA, LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 W PALISADE AVE
ENGLEWOOD NJ
07631-2611
US

IV. Provider business mailing address

2 PARK AVE
DUMONT NJ
07628-3004
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-6667
  • Fax:
Mailing address:
  • Phone: 201-385-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00158000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: