Healthcare Provider Details

I. General information

NPI: 1962459552
Provider Name (Legal Business Name): CENTERPATH WELLNESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 ROOSEVELT AVE
PLAINFIELD NJ
07060-1331
US

IV. Provider business mailing address

117 ROOSEVELT AVE
PLAINFIELD NJ
07060-1331
US

V. Phone/Fax

Practice location:
  • Phone: 908-756-6870
  • Fax: 908-756-5566
Mailing address:
  • Phone: 908-756-6870
  • Fax: 908-756-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number204050104
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0015105
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier7640706
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: JOSEPH DANIEL
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC
Phone: 908-756-6870