Healthcare Provider Details

I. General information

NPI: 1346656006
Provider Name (Legal Business Name): COR BEHAVIORAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 FLAGHOUSE DR
HASBROUCK HEIGHTS NJ
07604-3118
US

IV. Provider business mailing address

601 FLAGHOUSE DR
HASBROUCK HEIGHTS NJ
07604-3118
US

V. Phone/Fax

Practice location:
  • Phone: 201-660-8270
  • Fax: 201-660-8271
Mailing address:
  • Phone: 201-660-8270
  • Fax: 800-985-9749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-08-4116
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY MITCHELL POTTER
Title or Position: CHIEF CLINICAL OFFICER
Credential: BCBA LBA
Phone: 201-660-8270