Healthcare Provider Details

I. General information

NPI: 1962894899
Provider Name (Legal Business Name): PETER REAVEY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 SPRINGFIELD AVE # 210
SUMMIT NJ
07901-2601
US

IV. Provider business mailing address

PO BOX 502
BELMAR NJ
07719-0502
US

V. Phone/Fax

Practice location:
  • Phone: 908-273-5558
  • Fax: 908-273-3355
Mailing address:
  • Phone: 732-418-8729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35S100664500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: