Healthcare Provider Details

I. General information

NPI: 1063958148
Provider Name (Legal Business Name): YMCA OF GREATER MONMOUTH COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 MIDDLE RD
HAZLET NJ
07730-2428
US

IV. Provider business mailing address

166 MAIN ST
MATAWAN NJ
07747-3104
US

V. Phone/Fax

Practice location:
  • Phone: 732-290-9040
  • Fax: 732-566-0433
Mailing address:
  • Phone: 732-290-9040
  • Fax: 732-566-0433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number100002804
License Number StateNJ

VIII. Authorized Official

Name: LEEANN WAGNER
Title or Position: VICE PRESIDENT
Credential:
Phone: 732-290-9040