=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467986414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2017
-----------------------------------------------------
Last Update Date | 04/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 694 E PASSAIC AVE
-----------------------------------------------------
City | BLOOMFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07003-4429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-771-9391
-----------------------------------------------------
Fax | 973-771-9486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 7TH AVE FL 9
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MICHAEL MAZZOCCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 212-629-7939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | GH1033
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------