1093337396 NPI number — SUPPORTIVE SPACE COUNSELING CENTER

Table of content: (NPI 1093337396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093337396 NPI number — SUPPORTIVE SPACE COUNSELING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPPORTIVE SPACE COUNSELING CENTER
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093337396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2244
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLEMINGTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08822-2244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-313-9484
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1320 OUTLOOK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAINSIDE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07092-1411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-429-4451
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2020

Additional Information

Authorized Official

Authorized Official Last Name:
SCHOLZ
Authorized Official First Name:
LINDSAY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/CLINICAL DIRECTOR
Authorized Official Telephone Number:
609-429-4451

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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