Healthcare Provider Details

I. General information

NPI: 1558765594
Provider Name (Legal Business Name): SOUTH JERSEY PSYCHOLOGICAL AND COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S BROADWAY STE 7
PITMAN NJ
08071-2235
US

IV. Provider business mailing address

PO BOX 211
PITMAN NJ
08071-0211
US

V. Phone/Fax

Practice location:
  • Phone: 844-365-7676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number35S100500400
License Number StateNJ

VIII. Authorized Official

Name: STEPHEN KRAVCHUCK
Title or Position: PSYCHOLOGIST
Credential:
Phone: 844-365-7676