MEDICARE: MENTAL WELLNESS 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		NJ

General Provider Information

NPI Number	:	1720594898
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENTAL WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	555 NORTH AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-2404
Country	:	US
Telephone Number	:	201-410-7376
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 NORTH AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-2404
Country	:	US
Telephone Number	:	201-410-7376
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SAMUEL MALDONADO
Credential	:	PH.D.
Telephone Number	:	201-364-8474

Provider Enumeration Date	:	12/27/2017
Last Update Date	:	12/27/2017

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Directions to “MENTAL WELLNESS CENTER LLC ” Practice Location

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