Basic Information
Provider Information | |||||||||
NPI: | 1841697034 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEAST BEHAVIORAL SERVCIES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMISES NEW JERSEY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 670646 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752670646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6155677256 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 421 BETHEL RD | ||||||||
Address2: |   | ||||||||
City: | SOMERS POINT | ||||||||
State: | NJ | ||||||||
PostalCode: | 082442081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096410000 | ||||||||
FaxNumber: | 6093775274 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2014 | ||||||||
LastUpdateDate: | 12/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAPLESDEN | ||||||||
AuthorizedOfficialFirstName: | CHERYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 6155103708 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ELEMENTS BEHAVIORAL HEALTH, INC | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC, CHC, CHPC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.