Healthcare Provider Details

I. General information

NPI: 1578100558
Provider Name (Legal Business Name): THE DIFFERENCE OF ONE MENTORING AND SUPPORTIVE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MAPLEWOOD DR
MAPLE SHADE NJ
08052-1923
US

IV. Provider business mailing address

119 MAPLEWOOD DR
MAPLE SHADE NJ
08052-1923
US

V. Phone/Fax

Practice location:
  • Phone: 609-781-1196
  • Fax:
Mailing address:
  • Phone: 609-781-1196
  • Fax:

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 Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JOCELYN MUSE-TAYLOR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 609-781-1196