Healthcare Provider Details

I. General information

NPI: 1356685838
Provider Name (Legal Business Name): BUDDIES OF NEW JERSEY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 HUDSON ST
HACKENSACK NJ
07601-6823
US

IV. Provider business mailing address

149 HUDSON ST
HACKENSACK NJ
07601-6823
US

V. Phone/Fax

Practice location:
  • Phone: 201-489-2900
  • Fax:
Mailing address:
  • Phone: 201-489-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2000295-08
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0250431
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerPROVIDER ID

VIII. Authorized Official

Name: MR. EMIL VITALE
Title or Position: CLINICAL DIRECTOR
Credential: LCADC
Phone: 201-489-2900