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General NPI Number Information
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NPI Number | 1669663746
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Entity Type | Organization
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Legal Business Name | CHILDRENS INTENSIVE IN COMMUNITY PROGRAM
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 08/05/2007
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Provider Practice Location Address
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Address Line | 101 RT 130 S GRANT BUILDING SUITE 440
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City | CINNAMINSON
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State | NJ
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Zip | 08077-2845
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Country | US
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Telephone | 856-829-9440
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Fax |
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Provider Business Mailing Address
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Address Line | 101 RT 130 S GRANT BUILDING SUITE 440
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City | CINNAMINSON
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State | NJ
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Zip | 08077-2845
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Country | US
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Telephone | 856-829-9440
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Fax | 856-829-9444
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MOMAH G COOPER
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Credential |
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Telephone | 856-829-9440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PC003757
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 445L05145400
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License Number State | NJ
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