Basic Information
| Provider Information | |||||||||
| NPI: | 1669964185 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROWAN INTEGRATED SPECIAL NEEDS - BH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71356 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191761356 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 SALINA RD | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080804111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666034 | ||||||||
| FaxNumber: | 8565666208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | WORKMAN | ||||||||
| AuthorizedOfficialFirstName: | KELIYVETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE & CONTRACT | ||||||||
| AuthorizedOfficialTelephone: | 8565666831 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROWAN UNIVERSITY | ||||||||
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| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0491829 | 05 | NJ | MEDICAID |