| Portum Private Practice Llc | |
|
1465 Route 31 S Ste 11011102 Annandale NJ 08801-3129 | |
| (732) 614-0994 | |
| Not Available |
| Full Name | Portum Private Practice Llc |
|---|---|
| Speciality | Clinic/center - Adolescent And Children Mental Health |
| Location | 1465 Route 31 S Ste 11011102, Annandale, New Jersey |
| Authorized Official Name and Position | Jeffrey Allen Decker (CHIEF OPERATING OFFICER) |
| Authorized Official Contact | 7326140994 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Portum Private Practice Llc 1465 Route 31 S Ste 1101102 Annandale NJ 08801-3129 Ph: (732) 614-0994 | Portum Private Practice Llc 1465 Route 31 S Ste 11011102 Annandale NJ 08801-3129 Ph: (732) 614-0994 |
| NPI Number | 1255103388 |
|---|---|
| Provider Enumeration Date | 10/23/2023 |
| Last Update Date | 10/23/2023 |
| Certification Date | 10/23/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255103388 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0855X | Clinic/center - Adolescent And Children Mental Health | (* (Not Available)) | Primary |
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