Healthcare Provider Details

I. General information

NPI: 1265532436
Provider Name (Legal Business Name): DEPT. VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD BLDG. 57
LYONS NJ
07939-5001
US

IV. Provider business mailing address

52 HERCULES RD
KENVIL NJ
07847-2579
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax: 908-604-5850
Mailing address:
  • Phone: 973-927-7044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number44SC00041400
License Number StateNJ

VIII. Authorized Official

Name: MS. SUSAN LEE MOORE-MAGEE
Title or Position: CLINICAL COORDINATOR
Credential: MSW, LCSW
Phone: 908-647-0180