Provider Demographics
NPI:1457671372
Name:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MPH, LPC, LCADC,
Authorized Official - Phone:973-672-6900
Mailing Address - Street 1:60 EVERGREEN PL
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2106
Mailing Address - Country:US
Mailing Address - Phone:973-672-6901
Mailing Address - Fax:866-376-8262
Practice Address - Street 1:60 EVERGREEN PL
Practice Address - Street 2:SUITE 500
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2106
Practice Address - Country:US
Practice Address - Phone:973-672-6901
Practice Address - Fax:866-376-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000479-10261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0226220Medicaid