Healthcare Provider Details

I. General information

NPI: 1023455045
Provider Name (Legal Business Name): STP UP-4 DEVELOPMENTAL DISABILITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9060 PALISADE AVE SUITE003
NORTH BERGEN NJ
07047-6137
US

IV. Provider business mailing address

2339 HUDSON TER SIUTTE B5-A
FORT LEE NJ
07024-7930
US

V. Phone/Fax

Practice location:
  • Phone: 201-647-0407
  • Fax:
Mailing address:
  • Phone: 201-647-0407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberQUALIFIED PROVIDER
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberQUALIFIED PROVIDER
License Number StateNJ

VIII. Authorized Official

Name: LEONOR JAVIER
Title or Position: CEO
Credential: BS-SOCIAL WORK
Phone: 201-647-0407