Healthcare Provider Details

I. General information

NPI: 1487776738
Provider Name (Legal Business Name): PARK BENCH GROUP COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 BETHEL RD
SOMERS POINT NJ
08244-2081
US

IV. Provider business mailing address

421 BETHEL RD
SOMERS POINT NJ
08244-2081
US

V. Phone/Fax

Practice location:
  • Phone: 609-365-2601
  • Fax: 609-365-2519
Mailing address:
  • Phone: 609-365-2601
  • Fax: 609-365-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number200023007
License Number StateNJ

VIII. Authorized Official

Name: MRS. RANDI MASSEY-ALVARADO
Title or Position: CO-OWNER
Credential: LCSW, LCADC
Phone: 609-365-2601