Provider Demographics
NPI:1780062620
Name:TAVERAS, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:TAVERAS
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 1:590 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2522
Mailing Address - Country:US
Mailing Address - Phone:973-596-5101
Mailing Address - Fax:973-639-5049
Practice Address - Street 1:37 EVERGREEN PL
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2154
Practice Address - Country:US
Practice Address - Phone:973-266-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness