=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255464764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HUMAN GROWTH CENTER OF NEW JERSEY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1033 US HIGHWAY 46 STE 106
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-473-0800
-----------------------------------------------------
Fax | 973-473-8058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1033 US HIGHWAY 46 STE 106
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-473-0800
-----------------------------------------------------
Fax | 973-473-8058
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. KONSTANTIN MOUHTIS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 973-473-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | SIO3346
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------