Healthcare Provider Details

I. General information

NPI: 1750717005
Provider Name (Legal Business Name): THE CENTER FOR CHANGE AND RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 BOUND BROOK RD
MIDDLESEX NJ
08846-1437
US

IV. Provider business mailing address

1255 BOUND BROOK RD
MIDDLESEX NJ
08846-1437
US

V. Phone/Fax

Practice location:
  • Phone: 732-667-5567
  • Fax: 732-667-5568
Mailing address:
  • Phone: 732-667-5567
  • Fax: 732-667-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00151500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00419100
License Number StateNJ

VIII. Authorized Official

Name: MARIELENA MOTTA
Title or Position: PROGRAM ADMINISTRATOR
Credential: MS LCADC LPC
Phone: 732-667-5567