Healthcare Provider Details

I. General information

NPI: 1275918963
Provider Name (Legal Business Name): WILLOWGLEN ACADEMY-NEW JERSEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 TERRILL ROAD
PLAINFIELD NJ
07062
US

IV. Provider business mailing address

8 WILSON DRIVE
SPARTA NJ
07871-3491
US

V. Phone/Fax

Practice location:
  • Phone: 973-579-3700
  • Fax: 973-579-1786
Mailing address:
  • Phone: 973-579-3700
  • Fax: 973-579-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. PATRICIA BATES
Title or Position: CONTROLLER
Credential:
Phone: 973-579-3700