Provider Demographics
NPI:1407181472
Name:ACTIVITY AND HUMAN PERFORMANCE CENTER
Entity Type:Organization
Organization Name:ACTIVITY AND HUMAN PERFORMANCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:SEGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:973-632-0710
Mailing Address - Street 1:PO BOX 32396
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-0796
Mailing Address - Country:US
Mailing Address - Phone:973-632-0710
Mailing Address - Fax:973-645-9894
Practice Address - Street 1:95 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-3025
Practice Address - Country:US
Practice Address - Phone:201-332-7077
Practice Address - Fax:201-332-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2138261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)