Healthcare Provider Details

I. General information

NPI: 1780291542
Provider Name (Legal Business Name): BONNIE BRAE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 VALLEY ROAD
LIBERTY CORNER NJ
07938
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 TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL D. RIEGER
Title or Position: CEO
Credential: MSW
Phone: 908-647-4719