Provider Demographics
NPI:1093532608
Name:KETAMINE CARE MENTAL HEALTH COUNSELING LLC
Entity type:Organization
Organization Name:KETAMINE CARE MENTAL HEALTH COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ORLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTATA GOLDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:718-687-7924
Mailing Address - Street 1:250 PEHLE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SADDLE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07663-5835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8-02 PLYMOUTH DR
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1641
Practice Address - Country:US
Practice Address - Phone:718-687-7924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health