Healthcare Provider Details

I. General information

NPI: 1659898120
Provider Name (Legal Business Name): AMERICAN COMMUNITY CLINICAL OUTREACH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 ROSEVILLE AVE
NEWARK NJ
07107-1703
US

IV. Provider business mailing address

610 FOREST VIEW DR
AVENEL NJ
07001-2176
US

V. Phone/Fax

Practice location:
  • Phone: 973-481-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number173-040
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number173-040
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number173-040
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number173-040
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number173-404
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number173-040
License Number StateNJ
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number173-040
License Number StateNJ

VIII. Authorized Official

Name: DR. CANDRICK C. DARKASHADE
Title or Position: CHIEF ADMINISTRATOR
Credential: PHD
Phone: 848-467-1409