Healthcare Provider Details

I. General information

NPI: 1184129926
Provider Name (Legal Business Name): DEVELOPMENTAL DISABILITY AWARENESS WITH LOVE (DDAWL)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/13/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 W MAIN ST
BOONTON NJ
07005-1148
US

IV. Provider business mailing address

338 W MAIN ST
BOONTON NJ
07005-1148
US

V. Phone/Fax

Practice location:
  • Phone: 973-588-5370
  • Fax:
Mailing address:
  • Phone: 973-588-5370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: TYQUAN L. GRIFFIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 973-223-5197