Healthcare Provider Details

I. General information

NPI: 1396205563
Provider Name (Legal Business Name): ESSEX PSYCHIATRIC CENTER FOR CHILDREN & ADULTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CENTRAL AVE
NEWARK NJ
07102-1909
US

IV. Provider business mailing address

38 TALBOT ST
SOMERSET NJ
08873-4600
US

V. Phone/Fax

Practice location:
  • Phone: 201-805-6046
  • Fax:
Mailing address:
  • Phone: 201-805-6046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. SONIA DEMETRIOS
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 201-805-6046