=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992129159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR JOSEPH P PEDOTO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2014
-----------------------------------------------------
Last Update Date | 02/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 BLOOMFIELD AVE SUITE 7
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-783-7772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 HOLLAND CIR
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07871-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-650-4796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JOSEPH P PEDOTO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 973-650-4796
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 35S100299100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------