Healthcare Provider Details

I. General information

NPI: 1912958513
Provider Name (Legal Business Name): FAMILY SERVICE ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E WHITE HORSE PIKE
GALLOWAY NJ
08205-9565
US

IV. Provider business mailing address

3073 ENGLISH CREEK AVE STE 3
EGG HARBOR TWP NJ
08234-9711
US

V. Phone/Fax

Practice location:
  • Phone: 609-652-1600
  • Fax: 609-652-2226
Mailing address:
  • Phone: 609-569-0239
  • Fax: 609-569-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberN/A
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIE ECHO
Title or Position: VP OF CLINICAL SERVICES
Credential: MSW
Phone: 609-569-0239