Healthcare Provider Details

I. General information

NPI: 1295246510
Provider Name (Legal Business Name): FAITH ESSENCE SMASH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 PARIS AVE
NORTHVALE NJ
07647-2028
US

IV. Provider business mailing address

169 PARIS AVE
NORTHVALE NJ
07647-2028
US

V. Phone/Fax

Practice location:
  • Phone: 201-564-7861
  • Fax:
Mailing address:
  • Phone: 201-564-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number18KT00649900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number18KT00649900
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number18KT00649900
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number18KT00649900
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number18KT00649900
License Number StateNJ
# 6
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number18KT00649900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: