Basic Information
| Provider Information | |||||||||
| NPI: | 1821210501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUEL OF NEW JERSEY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CAPITAL ACADEMY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1131 EAGLETREE LN SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568803339 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1770 MOUNT EPHRAIM AVE | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081041837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094341001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 05/04/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GURULE | ||||||||
| AuthorizedOfficialFirstName: | YVONNE | ||||||||
| AuthorizedOfficialMiddleName: | ROSE | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5057109210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SYFS HOLDINGS, LLC | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | NJ | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 0124346 | 05 | NJ | MEDICAID |