Provider Demographics
NPI:1821530148
Name:AVITA INTEGRATIVE CARE, LLC
Entity Type:Organization
Organization Name:AVITA INTEGRATIVE CARE, LLC
Other - Org Name:AVITA ICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KALMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODIK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:888-242-2732
Mailing Address - Street 1:440 WEST ST STE 312
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5028
Mailing Address - Country:US
Mailing Address - Phone:888-242-2732
Mailing Address - Fax:888-242-2732
Practice Address - Street 1:440 WEST ST STE 312
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5028
Practice Address - Country:US
Practice Address - Phone:888-242-2732
Practice Address - Fax:888-242-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0450041113103T00000X, 103TC0700X
NY021116103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300123051Medicare PIN