Healthcare Provider Details

I. General information

NPI: 1902310196
Provider Name (Legal Business Name): WINTERTREE PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 VALLEY RD
MONTCLAIR NJ
07042-2331
US

IV. Provider business mailing address

31 COBBLESTONE TER
MONTVILLE NJ
07045-9490
US

V. Phone/Fax

Practice location:
  • Phone: 973-650-1832
  • Fax:
Mailing address:
  • Phone: 973-650-1832
  • 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 TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number44SC
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number44SC05749600
License Number StateNJ

VIII. Authorized Official

Name: KAREN LEE BENENSON
Title or Position: OWNER
Credential: MSW, LCSW
Phone: 973-650-1832