Provider Demographics
NPI:1366989881
Name:MENTAL HEALTH NOURISHMENT
Entity type:Organization
Organization Name:MENTAL HEALTH NOURISHMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN
Authorized Official - Prefix:
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-283-7409
Mailing Address - Street 1:81 2ND ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 2ND ST
Practice Address - Street 2:SUITE 8
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1861
Practice Address - Country:US
Practice Address - Phone:862-283-7409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-22
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00627000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty