Healthcare Provider Details

I. General information

NPI: 1356645923
Provider Name (Legal Business Name): YOUTH DEVELOPMENT SVCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N RTE 17 SUITE 313
PARAMUS NJ
07652-2644
US

IV. Provider business mailing address

12 N RTE 17 SUITE 313
PARAMUS NJ
07652-2644
US

V. Phone/Fax

Practice location:
  • Phone: 201-543-3935
  • Fax: 201-226-1141
Mailing address:
  • Phone: 201-543-3935
  • Fax: 201-226-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC05258800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. REBECCA HENRIQUEZ
Title or Position: LCSW
Credential: LCSW
Phone: 201-543-3935