Healthcare Provider Details

I. General information

NPI: 1114370657
Provider Name (Legal Business Name): PSYCHOLOGICAL CONSULTING AND THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 FRANKLIN TPKE SUITE 1-2
WALDWICK NJ
07463-1851
US

IV. Provider business mailing address

71 FRANKLIN TPKE SUITE 1-2
WALDWICK NJ
07463-1851
US

V. Phone/Fax

Practice location:
  • Phone: 201-497-0289
  • Fax: 866-850-6432
Mailing address:
  • Phone: 201-497-0289
  • Fax: 866-850-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05391100
License Number StateNJ

VIII. Authorized Official

Name: VALERY E FRADKOV
Title or Position: PRESIDENT
Credential: LCSW
Phone: 201-497-0289