PROV 205 LLC
NPI 1063963411
Psychologist in Bayonne, NJ

Active since October 20, 2016
866 BROADWAY, SUITE A, BAYONNE, NJ 07002(201) 455-2052(201) 354-9376 Get Directions Write a Review

NPPES record last updated: April 27, 2017. Verified against the NPPES registry weekly; last sync: October 25, 2026.

Record update history: Apr 27, 2017, Oct 20, 2016 (2 updates tracked since 2016).

About Prov 205 Llc NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

PROV 205 LLC (NPI 1063963411) is a healthcare organization registered as a psychologist in Bayonne, New Jersey and active in the NPI registry since October 2016. The organization lists Joel Nunez, Psychologist, as its authorized official.

NPPES Registry Identity

NPI1063963411
Entity TypeOrganization
Primary Taxonomy103T00000X
Legal Business NamePROV 205 LLC
Location Address866 BROADWAY, SUITE ABayonne, NJ 07002-3070
Mailing AddressPo Box 626New Providence, NJ 07974-0626 · (201) 455-2052 · Fax (201) 354-9376
Fax(201) 354-9376
Organization SubpartNo
Authorized OfficialJoel NunezPsychologist · (201) 455-2052
Enumeration DateOctober 20, 2016
Last NPPES UpdateApril 27, 20172 updates tracked since enumeration
✔ NPI 1063963411 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyPsychologistBehavioral Health & Social Service Providers
Taxonomy Code103T00000X
License✔ Licensed in NJ · 35SI00437200
Definition
A psychologist is an individual who is licensed to practice psychology which is defined as the observation, description, evaluation, interpretation, and modification of human behavior by the application of psychological principles, methods, and procedures, for the purpose of preventing or eliminating symptomatic, maladaptive, or undesired behavior and of enhancing interpersonal relationships, work and life adjustment, personal effectiveness, behavioral health, and mental health. The practice of psychology includes, but is not limited to, psychological testing and the evaluation or assessment of personal characteristics, such as intelligence, personality, abilities, interests, aptitudes, and neuropsychological functioning; counseling, psychoanalysis, psychotherapy, hypnosis, biofeedback, and behavior analysis and therapy; diagnosis and treatment of mental and emotional disorder or disability, alcoholism and substance abuse, disorders of habit or conduct, as well as of the psychological aspects of physical illness, accident, injury, or disability; and psycheducational evaluation, therapy, remediation, and consultation. Psychological services may be rendered to individuals, families, groups and the public.
866 BROADWAY, Bayonne, NJ 07002

Group Practice 1

Group TaxonomyThis provider is a business group of one or more individual practitioners, who practice with different areas of specialization.193200000X MULTI-SPECIALTY GROUP

Medicare Participation & PECOS CMS

Medicare enrollment and the clinicians who bill Medicare through this organization, from CMS.

Medicare Enrollment Status

✔

Enrolled in Medicare (PECOS)

Prov 205 Llc is registered in the CMS Provider Enrollment, Chain and Ownership System (PECOS).

Clinicians Billing Medicare Through This Organization

2

Medicare enrollment records show 2 clinicians reassign Medicare billing to Prov 205 LLC, which bills Medicare for the services they deliver. Of these, 2 practice within 10 miles. They are listed nearest first.

Clinicians, nearest first (2)

Clinical Psychologist
NPI 1376862235
510 BROADWAY
Bayonne, NJ 07002
(201) 455-2052
✔ PECOS1.0 mi
Mental Health Counselor
NPI 1881293009
100 WASHINGTON AVE 513
Belleville, NJ 07109
(973) 445-8171
✔ PECOS7.8 mi

Source: CMS Revalidation Reassignment List, October 2026 release. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Prov 205 LLC's NPI number?

The NPI number for Prov 205 LLC is 1063963411. It was assigned to this organization in the NPPES registry on October 20, 2016.

Where is Prov 205 LLC located?

Prov 205 LLC is located at 866 Broadway Suite A, Bayonne, NJ 07002. The listed phone number is (201) 455-2052.

What is Prov 205 LLC's specialty?

The primary specialty registered for this NPI is Psychologist with taxonomy code 103T00000X.

Is Prov 205 LLC enrolled in Medicare?

Yes. Prov 205 LLC is registered in the Medicare PECOS enrollment system.

How many clinicians bill Medicare through Prov 205 LLC?

According to the CMS Revalidation Reassignment List (October 2026 release), 2 clinicians reassign their Medicare billing to Prov 205 LLC, in Clinical Psychologist and Mental Health Counselor. A reassignment is filed with Medicare on form CMS-855R, signed by both the clinician and the organization, and lets the organization bill Medicare and receive payment for the clinician's services. Of these, 2 practice within 10 miles. Reassignment records can lag staffing changes; confirm a current affiliation with the organization.

When was this NPI record last updated?

The NPPES record for Prov 205 LLC was last updated on April 27, 2017. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 9 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.