=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841326931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACH BUNGALO LIMITED LIABILITY COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 892 COMMON WAY SUITE H
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-557-0354
-----------------------------------------------------
Fax | 732-286-4334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 712 E LONG BRANCH AVENUE
-----------------------------------------------------
City | BAYVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-557-0354
-----------------------------------------------------
Fax | 732-286-4334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. SHERRY LYNN GOLDMAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 732-557-0354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05201900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------