Provider Demographics
NPI:1811076607
Name:LIBERTY BEHAVIORAL HEALTH ASSOCIATES
Entity type:Organization
Organization Name:LIBERTY BEHAVIORAL HEALTH ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN, DEPT OF BEHAVIORAL HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:RITU
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-915-2000
Mailing Address - Street 1:395 GRAND ST
Mailing Address - Street 2:AMBULATORY CARE BUILDING
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-4238
Mailing Address - Country:US
Mailing Address - Phone:201-915-2600
Mailing Address - Fax:201-369-6301
Practice Address - Street 1:395 GRAND ST
Practice Address - Street 2:AMBULATORY CARE BUILDING
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4238
Practice Address - Country:US
Practice Address - Phone:201-915-2600
Practice Address - Fax:201-369-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7491808Medicaid
031093Medicare PIN