Basic Information
| Provider Information | |||||||||
| NPI: | 1871806059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOUSECALL PRACTITIONERS, PROFESSIONAL ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD CLIFFS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076321912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5515873252 | ||||||||
| FaxNumber: | 2012218427 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD CLIFFS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076321912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5515873252 | ||||||||
| FaxNumber: | 2012218427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | SEO | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5515873252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 26NJ0014370 | NJ | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0201049 | 05 | NJ | MEDICAID |