=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053801118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENVISION CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2018
-----------------------------------------------------
Last Update Date | 05/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 POMPTON AVE
-----------------------------------------------------
City | VERONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07044-2946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-271-5802
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 OLD CHESTER RD
-----------------------------------------------------
City | ESSEX FELLS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07021-1625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONSULTANT
-----------------------------------------------------
Name | JIM MOSCHELLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-699-1884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------