=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194447144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST MICHAEL MENTAL CARE CONSULT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2022
-----------------------------------------------------
Last Update Date | 09/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 WASHINGTON ST
-----------------------------------------------------
City | EAST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07017-1050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-304-5180
-----------------------------------------------------
Fax | 973-399-3786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 GRANT PL
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-304-5180
-----------------------------------------------------
Fax | 973-399-3786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APN/OWNER
-----------------------------------------------------
Name | MICHAEL ENWERE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-412-6427
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------