Provider Demographics
NPI:1952964611
Name:ARCHETYPE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:ARCHETYPE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON-POTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:646-820-5477
Mailing Address - Street 1:111 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:NETCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07857-1222
Mailing Address - Country:US
Mailing Address - Phone:973-527-4464
Mailing Address - Fax:
Practice Address - Street 1:444 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3012
Practice Address - Country:US
Practice Address - Phone:646-820-5477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health