Provider Demographics
NPI:1003392374
Name:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Other - Org Name:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CEO: ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DR. DANIEL
Authorized Official - Middle Name:ESTRADA
Authorized Official - Last Name:CASSELL, PH.D., MPH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH
Authorized Official - Phone:215-432-3702
Mailing Address - Street 1:291 PICKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1626
Mailing Address - Country:US
Mailing Address - Phone:908-777-3744
Mailing Address - Fax:908-777-3746
Practice Address - Street 1:291 PICKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1626
Practice Address - Country:US
Practice Address - Phone:908-777-3744
Practice Address - Fax:908-777-3746
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101950304261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ101950304OtherINTENSIVE OUTPATIENT MENTAL HEALTH SERVICES