Healthcare Provider Details

I. General information

NPI: 1780428623
Provider Name (Legal Business Name): PURPLEBLUE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/25/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 UNION AVE
IRVINGTON NJ
07111-3219
US

IV. Provider business mailing address

290 CLERMONT TER
UNION NJ
07083-8003
US

V. Phone/Fax

Practice location:
  • Phone: 551-358-7382
  • Fax:
Mailing address:
  • Phone: 551-358-7383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. REGINA INOKON
Title or Position: PMHNP-BC/CO-OWNER
Credential: APN, DNP
Phone: 551-358-7383