Provider Demographics
NPI:1457434904
Name:BAHARLIAS, JACK (PSYCHOLOGIST ED D)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BAHARLIAS
Suffix:
Gender:M
Credentials:PSYCHOLOGIST ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 RT 22 E
Mailing Address - Street 2:AMERICAN INSTITUTE FOR COUNSELING INC
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805
Mailing Address - Country:US
Mailing Address - Phone:732-469-6444
Mailing Address - Fax:732-469-6445
Practice Address - Street 1:1952 RT 22 E
Practice Address - Street 2:AMERICAN INSTITUTE FOR COUNSELING INC
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805
Practice Address - Country:US
Practice Address - Phone:732-469-6444
Practice Address - Fax:732-469-6445
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1823103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
429760PTUMedicare ID - Type Unspecified