Healthcare Provider Details

I. General information

NPI: 1710860614
Provider Name (Legal Business Name): MAGELLAN WELLNESS & PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2025
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 WOODMERE AVE
NEPTUNE NJ
07753-5636
US

IV. Provider business mailing address

516 WOODMERE AVE
NEPTUNE NJ
07753-5636
US

V. Phone/Fax

Practice location:
  • Phone: 908-309-5623
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DARIO MAGALHAES COSTA
Title or Position: DIRECTOR/FOUNDER
Credential: LPC
Phone: 908-309-5623