Provider Demographics
NPI:1932766847
Name:GARDEN STATE PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:GARDEN STATE PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-628-4504
Mailing Address - Street 1:58 EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-4626
Mailing Address - Country:US
Mailing Address - Phone:856-628-4504
Mailing Address - Fax:
Practice Address - Street 1:58 EUCLID ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-4626
Practice Address - Country:US
Practice Address - Phone:856-628-4504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-27
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ00000000Medicaid