Basic Information
| Provider Information | |||||||||
| NPI: | 1063020857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POSITIVE IMPACT BEHAVIORAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 178 NEWTON STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 171030710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3479127566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 178 NEWTON STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071030710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3479127566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2020 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | AKHIBI | ||||||||
| AuthorizedOfficialFirstName: | MARTINS | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 3479127566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PSYCHIATRIC NP | ||||||||
| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.