Provider Demographics
NPI:1134733389
Name:AUGUSTAVE, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:AUGUSTAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-6405
Mailing Address - Country:US
Mailing Address - Phone:201-562-3162
Mailing Address - Fax:
Practice Address - Street 1:33 WAYNE ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3541
Practice Address - Country:US
Practice Address - Phone:201-632-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty