Provider Demographics
NPI:1639957772
Name:IDEAL PSYCH BEHAVIORAL HEALTH LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:IDEAL PSYCH BEHAVIORAL HEALTH LIMITED LIABILITY COMPANY
Other - Org Name:IDEAL PSYCH BEHAVIORAL HEALTH LIMITED LIABILITY COMPANY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:WANYOIKE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:862-264-8062
Mailing Address - Street 1:23 QUINCY CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08810-1331
Mailing Address - Country:US
Mailing Address - Phone:862-264-8062
Mailing Address - Fax:
Practice Address - Street 1:1145 BORDENTOWN AVE, 3RD FLOOR ROOM 18
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-0885
Practice Address - Country:US
Practice Address - Phone:862-264-8062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty