Healthcare Provider Details

I. General information

NPI: 1003330846
Provider Name (Legal Business Name): POWER HOUSE PSYCHOTHERAPY & ADDICTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 07/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 MOUNT PROSPECT AVE STE 201
NEWARK NJ
07104-3110
US

IV. Provider business mailing address

654 MOUNT PROSPECT AVE STE 201
NEWARK NJ
07104-3110
US

V. Phone/Fax

Practice location:
  • Phone: 862-888-8146
  • Fax:
Mailing address:
  • Phone: 973-878-3900
  • Fax: 973-878-3809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00242600
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05667800
License Number StateNJ

VIII. Authorized Official

Name: TEMITOPE SHAKIRAT COATES
Title or Position: EXECUTIVE DIRECTOR/ADMINISTRATOR
Credential: LCSW, LCADC, CCS
Phone: 973-878-3900