=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629350434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COOPERATIVE COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2011
-----------------------------------------------------
Last Update Date | 03/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1139 SPRUCE DRIVE SUITE 2
-----------------------------------------------------
City | MOUNTAINSIDE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-731-7099
-----------------------------------------------------
Fax | 908-731-7102
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1139 SPRUCE DRIVE SUITE 2
-----------------------------------------------------
City | MOUNTAINSIDE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-731-7099
-----------------------------------------------------
Fax | 908-731-7102
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | ASHLEY JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-854-4651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------