=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891377503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANTAGE HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2021
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 93 W PALISADE AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-567-0500
-----------------------------------------------------
Fax | 201-567-9335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 93 W PALISADE AVE
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-567-0500
-----------------------------------------------------
Fax | 201-567-9335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNT MANAGER
-----------------------------------------------------
Name | BETTY TRELOAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-385-4400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------