Provider Demographics
NPI:1730954595
Name:MY PSYCH PROVIDER LLC
Entity type:Organization
Organization Name:MY PSYCH PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OKECHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:APN, PMHNP
Authorized Official - Phone:973-791-9365
Mailing Address - Street 1:100 ENTERPRISE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-2129
Mailing Address - Country:US
Mailing Address - Phone:973-791-9365
Mailing Address - Fax:973-869-2449
Practice Address - Street 1:100 ENTERPRISE DR STE 301
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-2129
Practice Address - Country:US
Practice Address - Phone:973-791-9365
Practice Address - Fax:973-869-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty