Healthcare Provider Details

I. General information

NPI: 1811489420
Provider Name (Legal Business Name): ROWANSOM NEWJERSEY INSTITUTE FOR SUCCESSFUL AGING-GERIATRIC PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 E LAUREL RD STE 1800
STRATFORD NJ
08084-1338
US

IV. Provider business mailing address

PO BOX 635
BELLMAWR NJ
08099-0635
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-6843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: KELIYVETTE WORKMAN
Title or Position: DIRECTOR MANAGED CARE & CONTRACTING
Credential:
Phone: 856-566-6831