Healthcare Provider Details

I. General information

NPI: 1174477038
Provider Name (Legal Business Name): RESTORATIVE THERAPY CENTER OF NEW JERSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 TOWN SQUARE PLACE SUITE 1201 1036
JERSEY CITY NJ
07310
US

IV. Provider business mailing address

111 TOWN SQUARE PLACE SUITE 1201 1036
JERSEY CITY NJ
07310
US

V. Phone/Fax

Practice location:
  • Phone: 201-897-2250
  • Fax:
Mailing address:
  • Phone: 201-897-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MEGAN DERISO
Title or Position: OWNER
Credential: PSY.D.
Phone: 201-897-2250