=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215388178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE HARBOR CHRISTIAN COUNSELING OF NEW JERSEY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2016
-----------------------------------------------------
Last Update Date | 06/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 CENTRAL AVE SUITE 100
-----------------------------------------------------
City | MOUNTAINSIDE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07092-1926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-893-4600
-----------------------------------------------------
Fax | 443-640-4358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 MOUNTAIN AVE
-----------------------------------------------------
City | SCOTCH PLAINS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07076-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL DIRECTOR
-----------------------------------------------------
Name | SHELLY YOST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-893-4600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------