Provider Demographics
NPI:1952654972
Name:ERIDIAN BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:ERIDIAN BEHAVIORAL HEALTH
Other - Org Name:PARK PLACE
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCADC
Authorized Official - Phone:732-869-2773
Mailing Address - Street 1:1011 BOND ST
Mailing Address - Street 2:
Mailing Address - City:ASBURY PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-5939
Mailing Address - Country:US
Mailing Address - Phone:732-859-1794
Mailing Address - Fax:
Practice Address - Street 1:1011 BOND ST
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-5939
Practice Address - Country:US
Practice Address - Phone:732-859-1794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERIDIAN HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05427900261QM0850X
NJ37LC00188000261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health