Basic Information
| Provider Information | |||||||||
| NPI: | 1831443894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FURTAW | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CENTURY PKWY STE 350 | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564829000 | ||||||||
| FaxNumber: | 8564821159 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CENTURY PKWY STE 350 | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564829000 | ||||||||
| FaxNumber: | 8564821159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 37PC00032200 | NJ | N | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC0700X | PS016071 | PA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 35SI00608700 | NJ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0687090 | 05 | NJ | MEDICAID | 826530 | 01 | NJ | MEDICARE | OTHER |