Provider Demographics
NPI:1093448599
Name:EZ MIND FAMILY MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:EZ MIND FAMILY MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP/FNP
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:609-916-6443
Mailing Address - Street 1:500 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANOKA HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08734-2228
Mailing Address - Country:US
Mailing Address - Phone:609-916-6443
Mailing Address - Fax:
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANOKA HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08734-2228
Practice Address - Country:US
Practice Address - Phone:609-916-6443
Practice Address - Fax:732-358-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-03
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1912564428Medicaid
NJ1912564428OtherCOMMERCIAL INSURANCE