Provider Demographics
NPI:1366685554
Name:HAMILTON, HENRY DUANE I (LCADC, ICADC, CAMF)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:DUANE
Last Name:HAMILTON
Suffix:I
Gender:M
Credentials:LCADC, ICADC, CAMF
Other - Prefix:MR
Other - First Name:HENRY
Other - Middle Name:DUANE
Other - Last Name:MUHAMMAD(HAMILTON)
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCADC
Mailing Address - Street 1:60 EVERGREEN PL STE 200&904
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2106
Mailing Address - Country:US
Mailing Address - Phone:973-678-3966
Mailing Address - Fax:973-678-3968
Practice Address - Street 1:60 EVERGREEN PL STE 200&904
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018
Practice Address - Country:US
Practice Address - Phone:973-678-6015
Practice Address - Fax:973-678-3968
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00118000101Y00000X, 207RA0401X, 390200000X, 101YA0400X
NJ37AC00086900101YM0800X
NJ37CL00118000101YP1600X
NJ44SC053638001041C0700X
NJNO106752363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0491187Medicaid
NJ0490717Medicaid
NJ11890384OtherCAQH
NJ8576195OtherAETNA