Healthcare Provider Details

I. General information

NPI: 1144938499
Provider Name (Legal Business Name): STAR ALLIANCE SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 CUTLER AVE
MAPLE SHADE NJ
08052-2914
US

IV. Provider business mailing address

615 CUTLER AVE
MAPLE SHADE NJ
08052-2914
US

V. Phone/Fax

Practice location:
  • Phone: 609-922-9061
  • Fax: 856-382-7926
Mailing address:
  • Phone: 609-922-9061
  • Fax: 856-382-7926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MISS PRISCILLA YAYRA KLUTSE
Title or Position: ADMINISTRATOR
Credential:
Phone: 609-922-9061