Healthcare Provider Details

I. General information

NPI: 1417356270
Provider Name (Legal Business Name): MR. DARNELL POUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HILLE PL
RIDGEFIELD PARK NJ
07660-2010
US

IV. Provider business mailing address

40 HILLE PL
RIDGEFIELD PARK NJ
07660-2010
US

V. Phone/Fax

Practice location:
  • Phone: 201-567-0500
  • Fax:
Mailing address:
  • Phone: 201-567-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: