=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407979669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTER SEALS NEW JERSEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2007
-----------------------------------------------------
Last Update Date | 08/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 MCDOWELL DR
-----------------------------------------------------
City | EAST BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08816-4087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-257-6662
-----------------------------------------------------
Fax | 732-257-7373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 FORSGATE DRIVE
-----------------------------------------------------
City | JAMESBURG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-257-6662
-----------------------------------------------------
Fax | 732-257-7373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF REVENUE
-----------------------------------------------------
Name | OMAR SOBERAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-955-8373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 40003-M40-00-41
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------