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General NPI Number Information
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NPI Number | 1851696983
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Entity Type | Organization
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Legal Business Name | INNOVATIVE LEARNING GROUP
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Dates
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Enumeration Date | 01/20/2011
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Last Update Date | 01/20/2011
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Provider Practice Location Address
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Address Line | 29 GARDEN AVE
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City | HAWTHORNE
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State | NJ
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Zip | 07506-1518
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Country | US
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Telephone | 973-886-8768
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 396
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City | HAWTHORNE
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State | NJ
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Zip | 07507-0396
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Country | US
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Telephone | 973-886-8768
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MARICRUZ CASTILLO
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Credential |
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Telephone | 973-886-8768
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1-10-7128
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License Number State | NJ
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