Healthcare Provider Details

I. General information

NPI: 1689137275
Provider Name (Legal Business Name): KAVELLE TRICIA MCGLASHAN BA, CADC INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
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

293 KINDERKAMACK RD APT B
RIVER EDGE NJ
07661-1879
US

V. Phone/Fax

Practice location:
  • Phone: 201-567-0500
  • Fax: 201-567-9335
Mailing address:
  • Phone: 201-888-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: