Provider Demographics
NPI:1174013262
Name:INTERVAL HEALTH LLC
Entity Type:Organization
Organization Name:INTERVAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PERERA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-337-0586
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07902-0014
Mailing Address - Country:US
Mailing Address - Phone:973-337-0586
Mailing Address - Fax:
Practice Address - Street 1:476 SOUTH AVE E
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-3204
Practice Address - Country:US
Practice Address - Phone:973-337-0586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC057202001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty