Healthcare Provider Details

I. General information

NPI: 1497152961
Provider Name (Legal Business Name): BONNIE BRAE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 VALLEY RD
BASKING RIDGE NJ
07920-2655
US

IV. Provider business mailing address

PO BOX 825
LIBERTY CORNER NJ
07938-0825
US

V. Phone/Fax

Practice location:
  • Phone: 908-542-2735
  • Fax: 908-647-5021
Mailing address:
  • Phone: 908-647-0800
  • Fax: 908-647-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. MEGAN JILL MACDONALD
Title or Position: ACCOUNTANT
Credential:
Phone: 908-542-2735