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General NPI Number Information
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NPI Number | 1720367832
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Entity Type | Organization
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Legal Business Name | INSYTE PSYCHIATRIC LLC
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Dates
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Enumeration Date | 08/06/2011
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Last Update Date | 08/06/2011
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Provider Practice Location Address
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Address Line | 33 PLYMOUTH ST SUITE 108
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City | MONTCLAIR
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State | NJ
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Zip | 07042-2677
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Country | US
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Telephone | 732-551-5550
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Fax |
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Provider Business Mailing Address
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Address Line | 33 PLYMOUTH ST SUITE 108
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City | MONTCLAIR
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State | NJ
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Zip | 07042-2677
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Country | US
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Telephone | 732-551-5550
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LYDIA KEISE
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Credential | M.D.
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Telephone | 732-551-5550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 25MA08706800
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License Number State | NJ
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