Healthcare Provider Details

I. General information

NPI: 1861923948
Provider Name (Legal Business Name): ST. ANNE'S MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 NAGLE AVE
NEW YORK NY
10040-1406
US

IV. Provider business mailing address

10 AUSTIN PL
CLIFTON NJ
07014-1901
US

V. Phone/Fax

Practice location:
  • Phone: 201-310-6947
  • Fax: 201-796-2205
Mailing address:
  • Phone: 201-310-6947
  • Fax: 201-796-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEANINE E. GRAVES
Title or Position: ADMINISTRATOR
Credential: OD
Phone: 201-310-6947