MEDICARE: NORTHERN NEW JERSEY COUNSELING CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	35S100528800	NJ

General Provider Information

NPI Number	:	1396152781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN NEW JERSEY COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	39 EAST MAIN STREET, 2ND FLOOR
Second Line	:
City	:	LITTLE FALLS
State	:	NJ
Zip	:	07424-2206
Country	:	US
Telephone Number	:	973-454-5569
Fax Number	:	973-454-5569

Provider Business Practice Location Address
First Line	:	39 EAST MAIN STREET, 2ND FLOOR
Second Line	:
City	:	LITTLE FALLS
State	:	NJ
Zip	:	07424-2206
Country	:	US
Telephone Number	:	973-454-5569
Fax Number	:	973-454-5569

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	ANASTASIA RAISA PYTAL
Credential	:	PSYD
Telephone Number	:	973-454-5569

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	07/17/2014

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