1578839973 NPI number — SPECTRUM BEHAVIOR SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578839973 NPI number — SPECTRUM BEHAVIOR SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM BEHAVIOR SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1578839973
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
443 17TH ST
Provider Second Line Business Mailing Address:
APT 2L
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11215-6233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
885 BROADWAY
Provider Second Line Business Practice Location Address:
#173
Provider Business Practice Location Address City Name:
BAYONNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07002-3087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-495-2411
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DEBERY
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-495-2411

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  01062727 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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