Healthcare Provider Details

I. General information

NPI: 1659526176
Provider Name (Legal Business Name): GARY ROSENBLUTH LDADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE SEARS DRIVE 3RD FL
PARAMUS NJ
07652
US

IV. Provider business mailing address

ONE SEARS DRIVE 3RD FL
PARAMUS NJ
07652
US

V. Phone/Fax

Practice location:
  • Phone: 201-967-0500
  • Fax: 201-967-0811
Mailing address:
  • Phone: 201-967-0500
  • Fax: 201-967-0811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00101200
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: