Provider Demographics
NPI:1942642095
Name:KEYSTONE PSYCHOLOGICAL GROUP, LLC
Entity Type:Organization
Organization Name:KEYSTONE PSYCHOLOGICAL GROUP, LLC
Other - Org Name:KEYSTONE PSYHCOLOGICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-549-0215
Mailing Address - Street 1:1861 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTCH PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07076-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 E NORTHFIELD RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4896
Practice Address - Country:US
Practice Address - Phone:917-549-0215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00038100101YP2500X
NJ44SC001383001041C0700X
NJ37FI00160600106H00000X
NJ25MA076428002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty