Provider Demographics
NPI:1851637557
Name:SPECIALIZED THERAPY ASSOCIATES LLC
Entity Type:Organization
Organization Name:SPECIALIZED THERAPY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURDINE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:201-488-6678
Mailing Address - Street 1:PO BOX 3016
Mailing Address - Street 2:
Mailing Address - City:SOUTH HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07606-1016
Mailing Address - Country:US
Mailing Address - Phone:201-488-6678
Mailing Address - Fax:201-342-4346
Practice Address - Street 1:83 SUMMIT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1262
Practice Address - Country:US
Practice Address - Phone:201-488-6678
Practice Address - Fax:201-342-4346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALIZED THERAPY ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty