Healthcare Provider Details

I. General information

NPI: 1396409645
Provider Name (Legal Business Name): GREAT MOMENTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3199
US

IV. Provider business mailing address

88 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3199
US

V. Phone/Fax

Practice location:
  • Phone: 201-757-0600
  • Fax: 800-507-2456
Mailing address:
  • Phone: 201-757-0600
  • Fax: 800-507-2456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. IDA JELTOVA
Title or Position: CLINICAL DIRECTOR
Credential: PHD
Phone: 201-757-0600