Provider Demographics
NPI:1861876419
Name:FAIRLAWN BEHAVIORAL ASSOCIATES LLC
Entity type:Organization
Organization Name:FAIRLAWN BEHAVIORAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTARTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-289-8455
Mailing Address - Street 1:PO BOX 809
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-0809
Mailing Address - Country:US
Mailing Address - Phone:201-342-4004
Mailing Address - Fax:201-243-7874
Practice Address - Street 1:15-01 BROADWAY
Practice Address - Street 2:SUITE# 10B
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6003
Practice Address - Country:US
Practice Address - Phone:201-342-4004
Practice Address - Fax:201-342-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA6506500103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7492201Medicaid
NJ073813Medicare PIN