Provider Demographics
NPI:1750680864
Name:INTROSPECTION, MIND,BODY&SPIRIT CENTER
Entity Type:Organization
Organization Name:INTROSPECTION, MIND,BODY&SPIRIT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GABLE-GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:973-931-2524
Mailing Address - Street 1:80 WATCHUNG AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1728
Mailing Address - Country:US
Mailing Address - Phone:973-931-2524
Mailing Address - Fax:973-338-1487
Practice Address - Street 1:1293 BROAD ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3060
Practice Address - Country:US
Practice Address - Phone:973-931-2524
Practice Address - Fax:973-338-1487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health