Provider Demographics
NPI:1750814950
Name:GREAT EXPECTATIONS CLINICAL AND SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:GREAT EXPECTATIONS CLINICAL AND SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-816-4948
Mailing Address - Street 1:263 HILLSIDE AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1180
Mailing Address - Country:US
Mailing Address - Phone:917-816-4948
Mailing Address - Fax:
Practice Address - Street 1:263 HILLSIDE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1180
Practice Address - Country:US
Practice Address - Phone:917-816-4948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health