Provider Demographics
NPI:1619374550
Name:HERBERT J TANNENBAUM PHD
Entity Type:Organization
Organization Name:HERBERT J TANNENBAUM PHD
Other - Org Name:CENTER FOR EFFECTIVE LIVING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-488-2997
Mailing Address - Street 1:1060 MAIN ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-2591
Mailing Address - Country:US
Mailing Address - Phone:201-488-2997
Mailing Address - Fax:
Practice Address - Street 1:1060 MAIN ST
Practice Address - Street 2:SUITE 306
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2591
Practice Address - Country:US
Practice Address - Phone:201-488-2997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1221103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1221OtherNJ DIV OF CONSUMER AFFAIRS LICENSCE NUMBER