1306454376 NPI number — SOUTH JERSEY THERAPY COLLECTIVE LLC

Table of content: (NPI 1306454376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306454376 NPI number — SOUTH JERSEY THERAPY COLLECTIVE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH JERSEY THERAPY COLLECTIVE 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:
6
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:
1306454376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1107 MANTUA PIKE, STE 701
Provider Second Line Business Mailing Address:
PMB 172
Provider Business Mailing Address City Name:
MANTUA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-225-9641
Provider Business Mailing Address Fax Number:
609-225-9641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 E MAIN ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08057-2920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-225-9641
Provider Business Practice Location Address Fax Number:
609-225-9641
Provider Enumeration Date:
07/16/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FLORESTA
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/PSYCHOTHERAPIST
Authorized Official Telephone Number:
609-225-9641

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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