Healthcare Provider Details

I. General information

NPI: 1093532608
Provider Name (Legal Business Name): KETAMINE CARE MENTAL HEALTH COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8-02 PLYMOUTH DR
FAIR LAWN NJ
07410-1641
US

IV. Provider business mailing address

250 PEHLE AVE STE 200
SADDLE BROOK NJ
07663-5835
US

V. Phone/Fax

Practice location:
  • Phone: 718-687-7924
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ORLY BENTATA GOLDENBERG
Title or Position: CEO
Credential: LMHC
Phone: 718-687-7924