Provider Demographics
NPI:1770330730
Name:STANFORD ANGELS CLEAR MIND AND WELLNESS LLC
Entity type:Organization
Organization Name:STANFORD ANGELS CLEAR MIND AND WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORK CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-814-2759
Mailing Address - Street 1:1600 SAINT GEORGES AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-2713
Mailing Address - Country:US
Mailing Address - Phone:848-336-0965
Mailing Address - Fax:908-248-0804
Practice Address - Street 1:1600 SAINT GEORGES AVE STE 301
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-2713
Practice Address - Country:US
Practice Address - Phone:848-336-0965
Practice Address - Fax:908-248-0804
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STANFORD ANGELS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-06
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty