Provider Demographics
NPI:1952773392
Name:FAIRLAWN BEHAVIORAL ASSOCIATES
Entity Type:Organization
Organization Name:FAIRLAWN BEHAVIORAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOHSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-821-2605
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-0809
Mailing Address - Country:US
Mailing Address - Phone:201-289-8455
Mailing Address - Fax:201-243-7874
Practice Address - Street 1:15-01 BROADWAY
Practice Address - Street 2:SUITE 10B
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6003
Practice Address - Country:US
Practice Address - Phone:201-794-7733
Practice Address - Fax:201-794-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ430413Medicare PIN