Healthcare Provider Details

I. General information

NPI: 1215206420
Provider Name (Legal Business Name): BETZAIDA PLAZA MHS-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 TATUM ST
WOODBURY NJ
08096-3499
US

IV. Provider business mailing address

97 ROOSEVELT AVE
ERIAL NJ
08081-9641
US

V. Phone/Fax

Practice location:
  • Phone: 856-845-8050
  • Fax: 856-845-0688
Mailing address:
  • Phone: 856-725-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: