Basic Information
Provider Information | |||||||||
NPI: | 1942653142 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KENNEDY BEHAVORIAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 454 HURFFVILLE CROSSKEYS RD | ||||||||
Address2: |   | ||||||||
City: | SEWELL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080802339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565821419 | ||||||||
FaxNumber: | 8565827661 | ||||||||
Practice Location | |||||||||
Address1: | 454 HURFFVILLE CROSSKEYS RD | ||||||||
Address2: |   | ||||||||
City: | SEWELL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080802339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565821419 | ||||||||
FaxNumber: | 8565827661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2016 | ||||||||
LastUpdateDate: | 07/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCULLEY | ||||||||
AuthorizedOfficialFirstName: | MEGAN | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | MASTER'S LEVEL CLINICIAN | ||||||||
AuthorizedOfficialTelephone: | 8565821419 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MS, LAC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 37AC00294300 | NJ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.