Basic Information
| Provider Information | |||||||||
| NPI: | 1154715449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TWIN RIVERS PSYCHOTHERAPY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 MONROE AVE | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077024017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327887835 | ||||||||
| FaxNumber: | 7328657190 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 AVENUE AT THE CMN | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SHREWSBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077024807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327887835 | ||||||||
| FaxNumber: | 7328657190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | O'DONNELL | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7327887835 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 44SC05541800 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1033557137 | 01 | NPI | OTHER |