Healthcare Provider Details

I. General information

NPI: 1922628155
Provider Name (Legal Business Name): THERACARE MANAGED SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 WALNUT AVE SUITE 105
CLARK NJ
07066-1640
US

IV. Provider business mailing address

1133 WESTCHESTER AVE. N230
WHITE PLAINS NY
10604-3516
US

V. Phone/Fax

Practice location:
  • Phone: 855-681-8555
  • Fax: 914-560-2102
Mailing address:
  • Phone: 212-564-2350
  • Fax: 212-564-2578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY CAROLINE MCCARTHY
Title or Position: DIRECTOR OF CONTRACT DEVELOPMENT
Credential:
Phone: 212-564-2350