Healthcare Provider Details

I. General information

NPI: 1447784475
Provider Name (Legal Business Name): CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 CENTRAL AVE
PLAINFIELD NJ
07060-2811
US

IV. Provider business mailing address

333 7TH AVE FL 9
NEW YORK NY
10001-5827
US

V. Phone/Fax

Practice location:
  • Phone: 908-755-3266
  • Fax: 908-755-3331
Mailing address:
  • Phone: 212-629-7939
  • Fax: 212-239-2211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberGH1227
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0471224
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MICHAEL MAZZOCCO
Title or Position: ASSISTANT EXECUTIVE DIRECTOR
Credential:
Phone: 212-629-7939