Healthcare Provider Details

I. General information

NPI: 1295386019
Provider Name (Legal Business Name): ROAD FOR SUCCESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 BASIN DR STE 190
KEARNY NJ
07032-6521
US

IV. Provider business mailing address

1303 BRISTOL STATION CT APT 1303
CARTERET NJ
07008-3092
US

V. Phone/Fax

Practice location:
  • Phone: 201-362-9360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHAN CRAWFORD
Title or Position: DIRECTOR
Credential: LSW, LCADC, CCS
Phone: 201-362-9360