Provider Demographics
NPI:1063947828
Name:THERACORP, LLC
Entity type:Organization
Organization Name:THERACORP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUTYANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:973-207-6834
Mailing Address - Street 1:79 E RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1207
Mailing Address - Country:US
Mailing Address - Phone:732-561-8555
Mailing Address - Fax:
Practice Address - Street 1:79 E RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:JAMESBURG
Practice Address - State:NJ
Practice Address - Zip Code:08831-1207
Practice Address - Country:US
Practice Address - Phone:732-561-8555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-28
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101Y00000X101Y00000X
NJ101YA0400X101YA0400X
NJ104200000X101YM0800X
NJ101YM0800X101YM0800X
NJ103T00000X103T00000X
NJ103TP0016X103TP0016X
NJ103TP2701X
NJ106H00000X106H00000X
NJ1041X0700X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty