Prov 205 LLC

NPI #1063963411 in Bayonne, New Jersey

Provider Information

NPI Number: 1063963411
Entity Type: Organization
Organization Name: Prov 205 LLC
Primary Specialty: Psychologist
Enumeration Date: Oct 20, 2016
Last Updated: Apr 27, 2017

Practice Location

Address: 866 BROADWAY
Address 2: SUITE A
City: Bayonne
State: New Jersey
ZIP Code: 07002-3070
Phone: (201) 455-2052

Authorized Official

Name: DR. JOEL NUNEZ, PH.D.
Title: PSYCHOLOGIST
Phone: (201) 455-2052

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Psychologist	103T00000X	Primary

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