Healthcare Provider Details

I. General information

NPI: 1063957603
Provider Name (Legal Business Name): THERAPEUTIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 S WHITE HORSE PIKE
SOMERDALE NJ
08083-1246
US

IV. Provider business mailing address

614 S WHITE HORSE PIKE
SOMERDALE NJ
08083-1246
US

V. Phone/Fax

Practice location:
  • Phone: 856-344-7982
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LANETTE KEETON
Title or Position: PRESIDENT
Credential:
Phone: 609-556-7783