=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811704513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN FAQUAN ESCOURSE SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2024
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 OBRIEN ST UNIT E7
-----------------------------------------------------
City | KEARNY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07032-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-231-5273
-----------------------------------------------------
Fax | 732-860-9883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 ASTORIA PL
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-231-5273
-----------------------------------------------------
Fax | 732-860-9883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------