Healthcare Provider Details

I. General information

NPI: 1013419704
Provider Name (Legal Business Name): LOTUS SPRING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 PROSPECT AVE APT 14E
HACKENSACK NJ
07601-2555
US

IV. Provider business mailing address

307 PROSPECT AVE APT 14E
HACKENSACK NJ
07601-2555
US

V. Phone/Fax

Practice location:
  • Phone: 201-525-1625
  • Fax:
Mailing address:
  • Phone: 201-525-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SC
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARYANN HOM
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 201-525-1625