Provider Demographics
NPI:1659819514
Name:FAMILY PROVISION LLC
Entity Type:Organization
Organization Name:FAMILY PROVISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:FIORDALIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANO
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:917-399-7281
Mailing Address - Street 1:81 INTERVALE RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 INTERVALE RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-6218
Practice Address - Country:US
Practice Address - Phone:917-399-7281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00600200305S00000X
NY0188081305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service