Healthcare Provider Details

I. General information

NPI: 1699063362
Provider Name (Legal Business Name): MIND BODY RECOVERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N STATE RT 17 SUITE 313
PARAMUS NJ
07652-2644
US

IV. Provider business mailing address

12 N STATE RT 17 SUITE 313
PARAMUS NJ
07652-2644
US

V. Phone/Fax

Practice location:
  • Phone: 201-543-3935
  • Fax: 201-226-1141
Mailing address:
  • Phone: 201-543-3935
  • Fax: 201-226-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SCO5258800
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: REBECCA HENRIQUEZ
Title or Position: PRESIDENT
Credential: LCSW
Phone: 201-543-3935