Healthcare Provider Details

I. General information

NPI: 1184403412
Provider Name (Legal Business Name): GUIDING BEACON 1 INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 MOUNTAIN AVE
NEW PROVIDENCE NJ
07974-2638
US

IV. Provider business mailing address

312 MOUNTAIN AVE
NEW PROVIDENCE NJ
07974-2638
US

V. Phone/Fax

Practice location:
  • Phone: 551-358-6742
  • Fax:
Mailing address:
  • Phone: 551-358-6742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SMITHA MANDAVA
Title or Position: OWNER & CEO
Credential:
Phone: 551-358-6742