Healthcare Provider Details

I. General information

NPI: 1780192401
Provider Name (Legal Business Name): DR. NAOMI AMBALU, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FRANKLIN TPKE STE 139
MAHWAH NJ
07430-1325
US

IV. Provider business mailing address

115 FRANKLIN TPKE STE 139
MAHWAH NJ
07430-1325
US

V. Phone/Fax

Practice location:
  • Phone: 908-998-2288
  • Fax: 705-995-2043
Mailing address:
  • Phone: 908-998-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NAOMI AMBALU
Title or Position: OWNER
Credential: DO
Phone: 908-998-2288