Basic Information
| Provider Information | |||||||||
| NPI: | 1700968187 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUTGERS HEALTH-RWJ SCLERODERMA PROGRAM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RUTGERS HEALTH-RWJ PSYCHOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | RED BAML | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 671 HOES LN | ||||||||
| Address2: | |||||||||
| City: | PISCATAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088545627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322354402 | ||||||||
| FaxNumber: | 7322354430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7322356070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 3456200 | 05 | NJ | MEDICAID |