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General NPI Number Information
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NPI Number | 1407193691
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Entity Type | Organization
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Legal Business Name | GERIATRIC PSYCHOLOGICAL SERVICES OF NEW JERSEY PC
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Dates
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Enumeration Date | 01/09/2013
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Last Update Date | 01/09/2013
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Provider Practice Location Address
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Address Line | 43 MAPLE AVE 2ND FLOOR SLOT 10
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City | MORRISTOWN
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State | NJ
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Zip | 07960-7508
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Country | US
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Telephone | 914-409-7632
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Fax |
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Provider Business Mailing Address
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Address Line | 11835 QUEENS BLVD SUITE 1403
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City | FOREST HILLS
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State | NY
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Zip | 11375-7200
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Country | US
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Telephone | 718-268-6600
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | TIMOTHY W WELLES
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Credential | ED.D
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Telephone | 914-409-7632
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 35SI00169400
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License Number State | NJ
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