MEDICARE: PRIMARY MDPSYCH LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QP2300X	Primary Care Clinic/Center
3	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1417618893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY MDPSYCH LLC

Provider Business Mailing Address
First Line	:	55 BONNIE DR
Second Line	:
City	:	MANALAPAN
State	:	NJ
Zip	:	07726-1858
Country	:	US
Telephone Number	:	561-420-6419
Fax Number	:

Provider Business Practice Location Address
First Line	:	11015 LEGACY LN APT 203
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-3612
Country	:	US
Telephone Number	:	561-420-6419
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MIRYAM ARJONA
Credential	:	LCSW
Telephone Number	:	561-420-6419

Provider Enumeration Date	:	01/06/2022
Last Update Date	:	01/06/2022

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