Healthcare Provider Details

I. General information

NPI: 1497505895
Provider Name (Legal Business Name): EJAJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 AYERS CT STE 2A
TEANECK NJ
07666-5160
US

IV. Provider business mailing address

1223 EMERSON AVE
TEANECK NJ
07666-2705
US

V. Phone/Fax

Practice location:
  • Phone: 201-530-7475
  • Fax:
Mailing address:
  • Phone: 201-315-1209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA SULTANIK
Title or Position: HEAD OF OPERATIONS
Credential:
Phone: 201-315-1209