Healthcare Provider Details

I. General information

NPI: 1326442567
Provider Name (Legal Business Name): WELLQOR PSYCHOLOGICAL SERVICES NORTHEAST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 RARITAN AVE
HIGHLAND PARK NJ
08904-3667
US

IV. Provider business mailing address

135 PINELAWN RD STE 204N
MELVILLE NY
11747-3133
US

V. Phone/Fax

Practice location:
  • Phone: 732-991-1540
  • Fax:
Mailing address:
  • Phone: 516-987-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER VIETZE
Title or Position: OWNER
Credential: PHD
Phone: 347-668-4992