1083727622 NPI number — THE NEW JERSEY INSTITUTE OF NEURBEHAVIOR

Table of content: (NPI 1083727622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083727622 NPI number — THE NEW JERSEY INSTITUTE OF NEURBEHAVIOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE NEW JERSEY INSTITUTE OF NEURBEHAVIOR
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:
1083727622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
665 MARTINSVILLE RD
Provider Second Line Business Mailing Address:
RIVERWALK VILLAGE CENTER, SUITE 218
Provider Business Mailing Address City Name:
BASKING RIDGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07920-4700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-604-1100
Provider Business Mailing Address Fax Number:
908-607-1866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
665 MARTINSVILLE RD
Provider Second Line Business Practice Location Address:
RIVERWALK VILLAGE CENTER, SUITE 218
Provider Business Practice Location Address City Name:
BASKING RIDGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07920-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-604-1100
Provider Business Practice Location Address Fax Number:
908-607-1866
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GILLOCK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
BRAGONIER
Authorized Official Title or Position:
DIRECTOR OF CLINICAL SERVICES
Authorized Official Telephone Number:
908-604-1100

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  1838 , 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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