Healthcare Provider Details

I. General information

NPI: 1144983412
Provider Name (Legal Business Name): PERRY ADREN MCCLAM PEER SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CENTRAL AVE # 1-L
HACKENSACK NJ
07601-3438
US

IV. Provider business mailing address

157 CENTRAL AVE # 1-L
HACKENSACK NJ
07601-3438
US

V. Phone/Fax

Practice location:
  • Phone: 973-930-1714
  • Fax:
Mailing address:
  • Phone: 973-930-1714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number50145
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: