Healthcare Provider Details

I. General information

NPI: 1104331891
Provider Name (Legal Business Name): PEDIATRIC & ADOLESCENT THERAPY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 N MOUNTAIN AVE
UPPER MONTCLAIR NJ
07043-1019
US

IV. Provider business mailing address

551 VALLEY RD STE 121
UPPER MONTCLAIR NJ
07043-1832
US

V. Phone/Fax

Practice location:
  • Phone: 973-534-2827
  • Fax:
Mailing address:
  • Phone: 973-534-2827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ARON LIPMAN
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 973-534-2827