Provider Demographics
NPI:1801533443
Name:DIAMOND VALLEY BEHAVIROAL LLC
Entity type:Organization
Organization Name:DIAMOND VALLEY BEHAVIROAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KALU
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:609-587-0113
Mailing Address - Street 1:427 HIGH ST UNIT 1823
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-4585
Mailing Address - Country:US
Mailing Address - Phone:609-587-0113
Mailing Address - Fax:609-388-8632
Practice Address - Street 1:427 HIGH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4587
Practice Address - Country:US
Practice Address - Phone:609-587-0113
Practice Address - Fax:609-388-6325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1245870658Medicaid