Provider Demographics
NPI:1609335736
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: ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DR. DANIEL
Authorized Official - Middle Name:ESTRADA
Authorized Official - Last Name:CASSELL, PH.D., MPH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH
Authorized Official - Phone:215-432-3702
Mailing Address - Street 1:19 HUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4803
Mailing Address - Country:US
Mailing Address - Phone:609-284-5822
Mailing Address - Fax:866-376-8262
Practice Address - Street 1:200 SOUTH ST
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-2151
Practice Address - Country:US
Practice Address - Phone:908-516-2338
Practice Address - Fax:866-376-8262
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KWENYAN PROFESSIONAL HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ101950404OtherNJ OFFICE OF LICENSING: OUTPATIENT MENTAL HEALTH SERVICES