Provider Demographics
NPI:1063175818
Name:CANAAN PSYCHIATRIC AND ADDICTION SERVICES LLC
Entity type:Organization
Organization Name:CANAAN PSYCHIATRIC AND ADDICTION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OBI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHIATRIC NP
Authorized Official - Phone:973-342-5593
Mailing Address - Street 1:1131 ELKER RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5006
Mailing Address - Country:US
Mailing Address - Phone:347-912-7566
Mailing Address - Fax:646-490-8780
Practice Address - Street 1:4377 BRONX BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1397
Practice Address - Country:US
Practice Address - Phone:347-912-7566
Practice Address - Fax:646-490-8780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5427909Medicaid