Provider Demographics
NPI:1801427810
Name:CLASSIC WELLNESS FAMILY MENTAL HEALTH PRACTICE LLC
Entity type:Organization
Organization Name:CLASSIC WELLNESS FAMILY MENTAL HEALTH PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHINENYE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKORO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP APN
Authorized Official - Phone:718-325-4669
Mailing Address - Street 1:1220 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 NORTH AVE STE 3
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7149
Practice Address - Country:US
Practice Address - Phone:718-325-4669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty