=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114881372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARAKA PSYCHIATRIC HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2025
-----------------------------------------------------
Last Update Date | 12/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1199 US HIGHWAY 22
-----------------------------------------------------
City | MOUNTAINSIDE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07092-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-534-2734
-----------------------------------------------------
Fax | 908-398-2660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2552 STANDISH AVE
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-4939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-534-2734
-----------------------------------------------------
Fax | 908-398-2660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APN/OWNER
-----------------------------------------------------
Name | FANTA MIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-534-2734
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------