Provider Demographics
NPI:1114396835
Name:MONTCLAIR MEMORY CLINIC LLC
Entity Type:Organization
Organization Name:MONTCLAIR MEMORY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:973-743-4555
Mailing Address - Street 1:PO BOX 8121
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-8121
Mailing Address - Country:US
Mailing Address - Phone:973-743-4555
Mailing Address - Fax:973-743-4055
Practice Address - Street 1:70 PARK STREET
Practice Address - Street 2:SUITE 207
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2960
Practice Address - Country:US
Practice Address - Phone:973-743-4555
Practice Address - Fax:973-743-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00390000103G00000X, 103TC0700X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0051560Medicaid
NJ0051560Medicaid