=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437871654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P & Q MENTAL HEALTH CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 01/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 RAVINE DR
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-753-4575
-----------------------------------------------------
Fax | 732-970-4956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 RAVINE DR
-----------------------------------------------------
City | MATAWAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07747-2965
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-753-4575
-----------------------------------------------------
Fax | 732-970-4956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRICS NURSE PRACTITIONER
-----------------------------------------------------
Name | OKSANA LIBELT
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 917-753-4575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------