Provider Demographics
NPI:1821208158
Name:COMPREHENSIVE PSYCHOLOGICAL AND WELLNESS CENTER,LLC
Entity Type:Organization
Organization Name:COMPREHENSIVE PSYCHOLOGICAL AND WELLNESS CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRANATO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:609-693-4343
Mailing Address - Street 1:424 S MAIN ST
Mailing Address - Street 2:UNIT F
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4641
Mailing Address - Country:US
Mailing Address - Phone:609-693-4343
Mailing Address - Fax:
Practice Address - Street 1:424 S MAIN ST
Practice Address - Street 2:UNIT F
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-4641
Practice Address - Country:US
Practice Address - Phone:609-693-4343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00429000103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2831657000OtherAMERIHEALTH GROUP NUMBER
NJY51457Medicare UPIN
NJ096689U32Medicare ID - Type UnspecifiedGROUP NUMBER