Healthcare Provider Details

I. General information

NPI: 1730328451
Provider Name (Legal Business Name): INTERSTATE FACTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 MAIN ST SUITE 102
HACKENSACK NJ
07601-7323
US

IV. Provider business mailing address

238 MAIN ST SUITE 102
HACKENSACK NJ
07601-7323
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-5188
  • Fax: 201-488-5189
Mailing address:
  • Phone: 201-488-5188
  • Fax: 201-488-5189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SC01011300
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. KATHRYN A DIXON
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 201-488-5188