Healthcare Provider Details

I. General information

NPI: 1114161825
Provider Name (Legal Business Name): THE YOUTH SUCCESS NETWORK - COMMUNILINK AND MHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 W MAIN ST FLOOR 2
FREEHOLD NJ
07728-2210
US

IV. Provider business mailing address

16 WEST MAIN ST FLOOR 2
FREEHOLD NJ
07728
US

V. Phone/Fax

Practice location:
  • Phone: 888-897-6465
  • Fax: 877-438-8976
Mailing address:
  • Phone: 888-897-6465
  • Fax: 877-438-8976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number64669006
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License NumberPENDING
License Number StateNJ

VIII. Authorized Official

Name: MR. M WELLESLEY GRAY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 888-897-6465