| Prov 205 Llc | |
|
866 Broadway Suite A Bayonne NJ 07002-3070 | |
| (201) 455-2052 | |
| (201) 354-9376 |
| Full Name | Prov 205 Llc |
|---|---|
| Speciality | Psychologist |
| Location | 866 Broadway, Bayonne, New Jersey |
| Authorized Official Name and Position | Joel Nunez (PSYCHOLOGIST) |
| Authorized Official Contact | 2014552052 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Prov 205 Llc Po Box 626 New Providence NJ 07974-0626 Ph: (201) 455-2052 | Prov 205 Llc 866 Broadway Suite A Bayonne NJ 07002-3070 Ph: (201) 455-2052 |
| NPI Number | 1063963411 |
|---|---|
| Provider Enumeration Date | 10/20/2016 |
| Last Update Date | 04/27/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063963411 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | 35SI00437200 (New Jersey) | Primary |
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