Healthcare Provider Details

I. General information

NPI: 1770295941
Provider Name (Legal Business Name): ICBH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MAPLE AVE STE WB2
RED BANK NJ
07701-1736
US

IV. Provider business mailing address

200 VILLAGE CENTER DR # 6722
FREEHOLD NJ
07728-1702
US

V. Phone/Fax

Practice location:
  • Phone: 732-668-4460
  • Fax:
Mailing address:
  • Phone: 732-668-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CLARISSA MULLIGAN ATTARA
Title or Position: COUNSELOR, SUPERVISOR, EDUCATOR
Credential: PHD, LPC, LCADC, ACS
Phone: 732-668-4460