Healthcare Provider Details

I. General information

NPI: 1699942391
Provider Name (Legal Business Name): MENTAL HEALTH ASSN OF ESSEX AND MORRIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 S FULLERTON AVE
MONTCLAIR NJ
07042
US

IV. Provider business mailing address

33 S FULLERTON AVE
MONTCLAIR NJ
07042-3358
US

V. Phone/Fax

Practice location:
  • Phone: 973-509-9777
  • Fax: 973-509-9218
Mailing address:
  • Phone: 973-509-9777
  • Fax: 973-509-9218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number302090405
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number302090405
License Number StateNJ

VIII. Authorized Official

Name: ROBERT N DAVISON
Title or Position: EXECUTIVE DIRECTOR
Credential: MA LPC
Phone: 973-509-9777