Provider Demographics
NPI:1811489420
Name:ROWANSOM NEWJERSEY INSTITUTE FOR SUCCESSFUL AGING-GERIATRIC PSYCHIATRY
Entity type:Organization
Organization Name:ROWANSOM NEWJERSEY INSTITUTE FOR SUCCESSFUL AGING-GERIATRIC PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR MANAGED CARE & CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:KELIYVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-566-6831
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08099-0635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 E LAUREL RD STE 1800
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1338
Practice Address - Country:US
Practice Address - Phone:856-566-6843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROWAN UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6946208Medicaid