Healthcare Provider Details

I. General information

NPI: 1710608351
Provider Name (Legal Business Name): GARY MICHAEL FURTAK PEER SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AIRPORT RD STE 7G
LAKEWOOD NJ
08701-5968
US

IV. Provider business mailing address

PO BOX 2036
LAKEWOOD NJ
08701-8036
US

V. Phone/Fax

Practice location:
  • Phone: 732-276-1510
  • Fax: 732-363-5537
Mailing address:
  • Phone: 732-276-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: