Healthcare Provider Details

I. General information

NPI: 1851825806
Provider Name (Legal Business Name): CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 MYRTLE ST
CLIFFWOOD NJ
07721-1218
US

IV. Provider business mailing address

333 7TH AVE FL 9
NEW YORK NY
10001-5827
US

V. Phone/Fax

Practice location:
  • Phone: 732-538-4199
  • Fax: 732-583-7681
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberGH1106A
License Number StateNJ

VIII. Authorized Official

Name: MICHAEL MAZZOCCO
Title or Position: ASSISTANT EXECUTIVE DIRECTOR
Credential:
Phone: 212-629-7939