Provider Demographics
NPI:1063963411
Name:PROV 205 LLC
Entity type:Organization
Organization Name:PROV 205 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-455-2052
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-0626
Mailing Address - Country:US
Mailing Address - Phone:201-455-2052
Mailing Address - Fax:201-354-9376
Practice Address - Street 1:866 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3070
Practice Address - Country:US
Practice Address - Phone:201-455-2052
Practice Address - Fax:201-354-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00437200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty