Basic Information
| Provider Information | |||||||||
| NPI: | 1346604808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST BEHAVIORAL SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PARK BENCH PROFESSIONAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670521 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752670521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155677256 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 421 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERS POINT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082442081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155677256 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 04/11/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAPLESDEN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 6155103708 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAVID A SACK, MD TN PC | ||||||||
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| AuthorizedOfficialCredential: | CPC, CHC, CHPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084F0202X | 25MA04602100 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 363LF0000X | 26NJ00062700 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 2084P0800X | 25MB06828200 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.