Provider Demographics
NPI:1669943528
Name:MOUNTAIN LAKES PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:MOUNTAIN LAKES PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:VANNEST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-710-4311
Mailing Address - Street 1:420 BOULEVARD STE 109
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1733
Mailing Address - Country:US
Mailing Address - Phone:201-710-4311
Mailing Address - Fax:973-588-4655
Practice Address - Street 1:420 BOULEVARD STE 109
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1733
Practice Address - Country:US
Practice Address - Phone:201-710-4311
Practice Address - Fax:973-588-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health