Provider Demographics
NPI:1407193691
Name:GERIATRIC PSYCHOLOGICAL SERVICES OF NEW JERSEY PC
Entity type:Organization
Organization Name:GERIATRIC PSYCHOLOGICAL SERVICES OF NEW JERSEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WELLES
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:914-409-7632
Mailing Address - Street 1:11835 QUEENS BLVD
Mailing Address - Street 2:SUITE 1403
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7200
Mailing Address - Country:US
Mailing Address - Phone:718-268-6600
Mailing Address - Fax:
Practice Address - Street 1:43 MAPLE AVE
Practice Address - Street 2:2ND FLOOR SLOT 10
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-7508
Practice Address - Country:US
Practice Address - Phone:914-409-7632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00169400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty