Healthcare Provider Details

I. General information

NPI: 1720170087
Provider Name (Legal Business Name): KINGSBORO PSYCHIATRIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 LAUREL AVENUE
TENAFLY NJ
07670
US

IV. Provider business mailing address

24 LAUREL AVENUE
TENAFLY NJ
07670
US

V. Phone/Fax

Practice location:
  • Phone: 201-568-5395
  • Fax:
Mailing address:
  • Phone: 201-568-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. DASEN M. BRAJKOVIC
Title or Position: ATTENDING PHYSICIAN
Credential: MD
Phone: 718-221-7391