Healthcare Provider Details

I. General information

NPI: 1780803452
Provider Name (Legal Business Name): NORTH JERSEY BEHAVIORAL MEDICINE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EXECUTIVE DR SUITE 665
FORT LEE NJ
07024-3308
US

IV. Provider business mailing address

1225 RIVER RD #8-D
EDGEWATER NJ
07020-1459
US

V. Phone/Fax

Practice location:
  • Phone: 201-669-2880
  • Fax: 718-504-4122
Mailing address:
  • Phone: 201-669-2880
  • Fax: 718-504-4122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MONA S. ISMAIL
Title or Position: OWNER
Credential: M.D.
Phone: 201-669-2880