| Garden State Psychiatric Services, Llc | |
|
58 Euclid St Woodbury NJ 08096-4626 | |
| (856) 628-4504 | |
| Not Available |
| Full Name | Garden State Psychiatric Services, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 58 Euclid St, Woodbury, New Jersey |
| Authorized Official Name and Position | Diane Wright (APN) |
| Authorized Official Contact | 8566284504 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Garden State Psychiatric Services, Llc 58 Euclid St Woodbury NJ 08096-4626 Ph: (856) 628-4504 | Garden State Psychiatric Services, Llc 58 Euclid St Woodbury NJ 08096-4626 Ph: (856) 628-4504 |
| NPI Number | 1932766847 |
|---|---|
| Provider Enumeration Date | 05/27/2019 |
| Last Update Date | 10/03/2019 |
| Medicare PECOS PAC ID | 0143550392 |
|---|---|
| Medicare Enrollment ID | O20191001002322 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1932766847 | NPI | - | NPPES |
| 00000000 | Medicaid | NJ |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Diane Wright |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1689961237 PECOS PAC ID: 5799939682 Enrollment ID: I20130130000182 |
| Provider Name | Lauren Antonison |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235538091 PECOS PAC ID: 8729200589 Enrollment ID: I20141111000307 |
| Provider Name | Heather C Wilmore |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194123133 PECOS PAC ID: 4981920626 Enrollment ID: I20150224001112 |
| Provider Name | Andrew Groves |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1104013309 PECOS PAC ID: 3577694272 Enrollment ID: I20150514001901 |
| Provider Name | Emily J Bacon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1962869016 PECOS PAC ID: 5698066033 Enrollment ID: I20160615001754 |
| Provider Name | Brian Portanova |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1336595800 PECOS PAC ID: 0446530307 Enrollment ID: I20161212000070 |
| Provider Name | Grace A Flynn |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1255857694 PECOS PAC ID: 4789958174 Enrollment ID: I20170925000376 |
| Provider Name | Joanne Marie Harris |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1407325624 PECOS PAC ID: 0941546097 Enrollment ID: I20190109003225 |
| Provider Name | Leeanne Mccauley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1225650302 PECOS PAC ID: 9638590128 Enrollment ID: I20200610000093 |
| Provider Name | Ryan Samuel Wooden |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1558032821 PECOS PAC ID: 8921492844 Enrollment ID: I20220218000517 |
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