Healthcare Provider Details

I. General information

NPI: 1760901623
Provider Name (Legal Business Name): PRODIGAL SONS AND DAUGHTERS BEHAVIORAL HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 EVERGREEN PL STE 904
EAST ORANGE NJ
07018-2114
US

IV. Provider business mailing address

PO BOX 28109
NEWARK NJ
07101-2486
US

V. Phone/Fax

Practice location:
  • Phone: 973-678-3966
  • Fax: 973-678-3968
Mailing address:
  • Phone: 973-703-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number100230104
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number2000609
License Number StateNJ

VIII. Authorized Official

Name: MR. HENRY DUANE MUHAMMAD-HAMILTON SR.
Title or Position: FOUNDER/CEO
Credential: MS, LCADC, ICADC
Phone: 973-678-3966