Healthcare Provider Details

I. General information

NPI: 1194379255
Provider Name (Legal Business Name): BACK ON TRACK COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2019
Last Update Date: 07/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 ORANGE PL
IRVINGTON NJ
07111-2019
US

IV. Provider business mailing address

19 ORANGE PL
IRVINGTON NJ
07111-2019
US

V. Phone/Fax

Practice location:
  • Phone: 973-474-8441
  • Fax:
Mailing address:
  • Phone: 973-474-8441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MUSTAFA SHAKIR ABDUS-SALAAM
Title or Position: CEO
Credential: MHS-C,LPC, LCADC
Phone: 862-217-5144