Provider Demographics
NPI:1629221239
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:EXECUTIVE DIRECTOR/PRESIDENT
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:973-672-6900
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:973-672-6900
Practice Address - Fax:866-376-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00330900101YP2500X
NJ37LC00040000103TA0400X
PALPC004779251S00000X
NJ26NR13660400374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0175366Medicaid