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General NPI Number Information
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NPI Number | 1942642095
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Entity Type | Organization
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Legal Business Name | KEYSTONE PSYCHOLOGICAL GROUP, LLC
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Dates
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Enumeration Date | 07/17/2013
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Last Update Date | 07/17/2013
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Provider Practice Location Address
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Address Line | 315 E NORTHFIELD RD SUITE 3A
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City | LIVINGSTON
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State | NJ
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Zip | 07039-4896
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Country | US
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Telephone | 917-549-0215
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Fax |
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Provider Business Mailing Address
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Address Line | 1861 LAKE AVE
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City | SCOTCH PLAINS
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State | NJ
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Zip | 07076-2919
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. CHRISTINE MACMILLAN
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Credential | M.D.
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Telephone | 917-549-0215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 37PC00038100
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC00138300
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 37FI00160600
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License Number State | NJ
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 25MA07642800
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License Number State | NJ
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