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General NPI Number Information
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NPI Number | 1174013262
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Entity Type | Organization
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Legal Business Name | INTERVAL HEALTH LLC
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Dates
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Enumeration Date | 05/14/2018
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Last Update Date | 03/29/2019
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Provider Practice Location Address
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Address Line | 476 SOUTH AVE E
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City | CRANFORD
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State | NJ
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Zip | 07016-3204
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Country | US
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Telephone | 973-337-0586
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 14
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City | SUMMIT
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State | NJ
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Zip | 07902-0014
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Country | US
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Telephone | 973-337-0586
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JENNIFER LYNN PERERA
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Credential | LCSW
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Telephone | 973-337-0586
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC05720200
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License Number State | NJ
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