Basic Information
| Provider Information | |||||||||
| NPI: | 1770836025 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERIDIAN BEHAVIORAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PARK PLACE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 BOND ST | ||||||||
| Address2: | |||||||||
| City: | ASBURY PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077125939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328692769 | ||||||||
| FaxNumber: | 7328979541 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 BOND ST | ||||||||
| Address2: | |||||||||
| City: | ASBURY PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077125939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328692769 | ||||||||
| FaxNumber: | 7328979541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AFFA | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER/INTAKE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7328692769 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERIDIAN HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 44SL05734800 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.