Provider Demographics
NPI:1346438793
Name:ANNANDALE SQUARE COUNSELING CENTER, P.C.
Entity Type:Organization
Organization Name:ANNANDALE SQUARE COUNSELING CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:REIDAR
Authorized Official - Last Name:WIDTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-832-7502
Mailing Address - Street 1:67 BEAVER AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ANNANDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:08801-3071
Mailing Address - Country:US
Mailing Address - Phone:908-238-0065
Mailing Address - Fax:908-238-0067
Practice Address - Street 1:67 BEAVER AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:ANNANDALE
Practice Address - State:NJ
Practice Address - Zip Code:08801-3071
Practice Address - Country:US
Practice Address - Phone:908-238-0065
Practice Address - Fax:908-238-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100389600103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty