Healthcare Provider Details

I. General information

NPI: 1720321094
Provider Name (Legal Business Name): C-LINE COMMUNITY OUTREACH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 BROADWAY
PATERSON NJ
07514-1524
US

IV. Provider business mailing address

680 BROADWAY
PATERSON NJ
07514-1524
US

V. Phone/Fax

Practice location:
  • Phone: 973-782-4828
  • Fax:
Mailing address:
  • Phone: 973-782-4828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00195700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00319300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37L00122100
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number200511-11
License Number StateNJ

VIII. Authorized Official

Name: MS. CAROLINE NELSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, CSW, LCADC
Phone: 973-782-4828