=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982000600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTH AND WELLNESS SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2014
-----------------------------------------------------
Last Update Date | 11/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 RIVER RD SUITE 8
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07901-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-273-6464
-----------------------------------------------------
Fax | 908-273-6161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 RIVER RD SUITE 8
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07901-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-273-6464
-----------------------------------------------------
Fax | 908-273-6161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSCYCHOLOGIST/FOUNDER
-----------------------------------------------------
Name | DR. RACHEL GINGOLD
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 908-273-6464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 4422
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------