Healthcare Provider Details

I. General information

NPI: 1598781973
Provider Name (Legal Business Name): BLOOMFIELD HEALTH PAVILION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 BLOOMFIELD AVE 1ST FLOOR & BASEMENT
NEWARK NJ
07104-1905
US

IV. Provider business mailing address

86 BLOOMFIELD AVE 1ST FLOOR & BASEMENT
NEWARK NJ
07104-1905
US

V. Phone/Fax

Practice location:
  • Phone: 973-230-3631
  • Fax: 973-230-3474
Mailing address:
  • Phone: 973-230-3631
  • Fax: 973-230-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number051A267
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number051A267
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number051A267
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number051A267
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number051A267
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number051A267
License Number StateNJ
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number051A267
License Number StateNJ
# 8
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number051A267
License Number StateNJ
# 9
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNJ
# 10
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNJ
# 11
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number StateNJ

VIII. Authorized Official

Name: MR. ROSTISLAV VILSHTEYN
Title or Position: CEO
Credential:
Phone: 718-813-4556