1720412885 NPI number — CHILD AND ADOLESCENT PSYCHIATRY OF SOUTHERN NEW JERSEY

Table of content: MRS. MELANIE THIBODEAUX LINER M.C.D (NPI 1699935569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720412885 NPI number — CHILD AND ADOLESCENT PSYCHIATRY OF SOUTHERN NEW JERSEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILD AND ADOLESCENT PSYCHIATRY OF SOUTHERN NEW JERSEY
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:
1720412885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1525 PLEASANT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHERRY HILL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08003-3129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-806-5333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 MARLTON PIKE E
Provider Second Line Business Practice Location Address:
SUITE Q-12
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08003-2150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-806-5333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
NEFF
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER/FOUNDER
Authorized Official Telephone Number:
215-806-5333

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  26NJ00123800 , 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)

  • Identifier: 1710041496 . This is a "NPI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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