Healthcare Provider Details

I. General information

NPI: 1679997100
Provider Name (Legal Business Name): LATIN AMERICAN INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BANTA PL STE 110
HACKENSACK NJ
07601-5605
US

IV. Provider business mailing address

10 BANTA PL STE 110
HACKENSACK NJ
07601-5605
US

V. Phone/Fax

Practice location:
  • Phone: 201-525-1700
  • Fax: 201-525-0544
Mailing address:
  • Phone: 201-525-1700
  • Fax: 201-525-0544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2000433
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number2000433
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2000433
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number2000433
License Number StateNJ

VIII. Authorized Official

Name: MRS. SARA DE BERNAL
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD,LCADC,CASAC
Phone: 201-289-2832