Healthcare Provider Details

I. General information

NPI: 1992933634
Provider Name (Legal Business Name): XANADU BEHAVIOR THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LACEY RD SUITE 3
FORKED RIVER NJ
08731-2200
US

IV. Provider business mailing address

615 LACEY RD SUITE 3
FORKED RIVER NJ
08731-2200
US

V. Phone/Fax

Practice location:
  • Phone: 609-242-3322
  • Fax: 609-242-3333
Mailing address:
  • Phone: 609-242-3322
  • Fax: 609-242-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-06-2178
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL04976200
License Number StateNJ

VIII. Authorized Official

Name: MS. STACIE GROELING
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 609-242-3322