Basic Information
| Provider Information | |||||||||
| NPI: | 1811489420 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROWANSOM NEWJERSEY INSTITUTE FOR SUCCESSFUL AGING-GERIATRIC PSYCHIATRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | BELLMAWR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080990635 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD STE 1800 | ||||||||
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| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | WORKMAN | ||||||||
| AuthorizedOfficialFirstName: | KELIYVETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR MANAGED CARE & CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 8565666831 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROWAN UNIVERSITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6946208 | 05 | NJ | MEDICAID |