1770969065 NPI number — DEVEREUX BRIDGETON

Table of content: MRS. ADDISON HOPE THURSTON M.S, CCC-SLP (NPI 1326811316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770969065 NPI number — DEVEREUX BRIDGETON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEVEREUX BRIDGETON
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:
1770969065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
286 MANTUA GROVE RD
Provider Second Line Business Mailing Address:
BUILDING #4
Provider Business Mailing Address City Name:
WEST DEPTFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08066-1738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-599-6400
Provider Business Mailing Address Fax Number:
856-599-6404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
198 ROADSTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08302-5747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-599-6400
Provider Business Practice Location Address Fax Number:
856-599-6404
Provider Enumeration Date:
08/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CIRUCCI
Authorized Official First Name:
CAROLE
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE DIRECTOR
Authorized Official Telephone Number:
856-599-6429

Provider Taxonomy Codes

  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0399507 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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