Basic Information
| Provider Information | |||||||||
| NPI: | 1912316639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENUINE ME OF SOUTH JERSEY INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GENUINE ME LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 CRANBURY HILL CT | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080544849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098280097 | ||||||||
| FaxNumber: | 8568020885 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098280097 | ||||||||
| FaxNumber: | 8568020885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | FADOOL | ||||||||
| AuthorizedOfficialFirstName: | JOANNE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6098280097 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 44SC05576600 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0450088977 | 01 | NJ | NEW JERSERY CERTIFICATE OF INC (PROFIT) | OTHER |