Healthcare Provider Details

I. General information

NPI: 1508220922
Provider Name (Legal Business Name): BONNIE BRAE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 VALLEY ROAD
LIBERTY CORNER NJ
07938-0825
US

IV. Provider business mailing address

PO BOX 825
LIBERTY CORNER NJ
07938-0825
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0800
  • Fax: 908-647-5021
Mailing address:
  • Phone: 908-647-0800
  • Fax: 908-647-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM M. POWERS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MHA, MPA
Phone: 908-647-0800