Provider Demographics
NPI:1396409645
Name:GREAT MOMENTS
Entity Type:Organization
Organization Name:GREAT MOMENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JELTOVA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-757-0600
Mailing Address - Street 1:88 W RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3199
Mailing Address - Country:US
Mailing Address - Phone:201-757-0600
Mailing Address - Fax:800-507-2456
Practice Address - Street 1:88 W RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3199
Practice Address - Country:US
Practice Address - Phone:201-757-0600
Practice Address - Fax:800-507-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-22
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty