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General NPI Number Information
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NPI Number | 1336975259
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Entity Type | Organization
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Legal Business Name | PORTUM BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 09/09/2024
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Last Update Date | 12/06/2024
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Provider Practice Location Address
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Address Line | 1465 ROUTE 31 S STE 1101
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City | ANNANDALE
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State | NJ
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Zip | 08801-3129
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Country | US
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Telephone | 551-306-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 1465 ROUTE 31 S STE 1101
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City | ANNANDALE
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State | NJ
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Zip | 08801-3129
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Country | US
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Telephone | 551-306-4000
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | JEFFREY ALLEN DECKER
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Credential | MHA
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Telephone | 732-614-0994
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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