1659531242 NPI number — MS. PHYLLIS MARIE MATICHAK LCADC PENDING

Table of content: MS. PHYLLIS MARIE MATICHAK LCADC PENDING (NPI 1659531242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659531242 NPI number — MS. PHYLLIS MARIE MATICHAK LCADC PENDING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATICHAK
Provider First Name:
PHYLLIS
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCADC PENDING
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659531242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E HANOVER AVE FL 1
Provider Second Line Business Mailing Address:
SAINT CLARE'S BEHAVIORAL HEALTH CENTER
Provider Business Mailing Address City Name:
CEDAR KNOLLS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07927-2020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-401-2170
Provider Business Mailing Address Fax Number:
973-401-2183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E HANOVER AVE FL 1
Provider Second Line Business Practice Location Address:
SAINT CLARE'S BEHAVIORAL HEALTH CENTER
Provider Business Practice Location Address City Name:
CEDAR KNOLLS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07927-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-401-2170
Provider Business Practice Location Address Fax Number:
973-401-2183
Provider Enumeration Date:
06/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LCADC PENDING , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: NOT LICENSED , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)