Provider Demographics
NPI:1912789215
Name:MBJ PSYCHIATRIC NURSE PRACTITIONER LLC
Entity type:Organization
Organization Name:MBJ PSYCHIATRIC NURSE PRACTITIONER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNST
Authorized Official - Middle Name:
Authorized Official - Last Name:RENONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:609-575-8483
Mailing Address - Street 1:6 KILMER RD STE B
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2432
Mailing Address - Country:US
Mailing Address - Phone:640-266-4033
Mailing Address - Fax:
Practice Address - Street 1:244 HENDRICKSON AVE
Practice Address - Street 2:
Practice Address - City:EDGEWATER PARK
Practice Address - State:NJ
Practice Address - Zip Code:08010-2024
Practice Address - Country:US
Practice Address - Phone:609-575-8483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)