Healthcare Provider Details

I. General information

NPI: 1518909837
Provider Name (Legal Business Name): LONG BEACH ISLAND COMMUNITY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LONG BEACH BLVD
LONG BEACH TOWNSHIP NJ
08008-3926
US

IV. Provider business mailing address

4700 LONG BEACH BLVD
LONG BEACH TOWNSHIP NJ
08008-3926
US

V. Phone/Fax

Practice location:
  • Phone: 609-494-1554
  • Fax: 609-361-9653
Mailing address:
  • Phone: 609-494-1554
  • Fax: 609-361-9653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNJ

VIII. Authorized Official

Name: DR. ROBERT T. HAZLETT
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW, PH.D
Phone: 609-494-1554