Provider Demographics
NPI:1154526440
Name:PASCACK MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:PASCACK MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BECERRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-391-1355
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:114 KINDERKAMACK ROAD
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-2126
Mailing Address - Country:US
Mailing Address - Phone:201-391-1355
Mailing Address - Fax:201-391-9516
Practice Address - Street 1:114 KINDERKAMACK ROAD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-2126
Practice Address - Country:US
Practice Address - Phone:201-391-1355
Practice Address - Fax:201-391-9516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0020303Medicaid
NJ0020303Medicaid