1487141883 NPI number — GENESIS ADDICTION AND BEHAVIORAL MEDICINE, LLC

Table of content: MS. LORRAINE DIANE JOLLY LMT (NPI 1366697955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487141883 NPI number — GENESIS ADDICTION AND BEHAVIORAL MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS ADDICTION AND BEHAVIORAL MEDICINE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487141883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
179 HIGH ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07860-1010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-862-4297
Provider Business Mailing Address Fax Number:
973-327-7760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
179 HIGH ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07860-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-862-4297
Provider Business Practice Location Address Fax Number:
973-327-7760
Provider Enumeration Date:
04/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GANON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
973-862-4297

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X , with the licence number:  25MB05783900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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