=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477102507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EQUINE ASSISTED THERAPY AND HANDICAPPED RIDING OF NJ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2019
-----------------------------------------------------
Last Update Date | 09/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 SWEDES BRIDGE RD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08079-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-617-2765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 SWEDES BRIDGE RD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08079-4019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-617-2765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JEANNE MARY MAHONEY
-----------------------------------------------------
Credential | RN, LPC
-----------------------------------------------------
Telephone | 609-617-2765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------