=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831588094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MH AT FREEHOLD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2015
-----------------------------------------------------
Last Update Date | 01/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4345 US HIGHWAY 9 STE 28
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-410-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2328 10TH AVE N STE 302
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-6612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JAMES STOKES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-410-4400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------