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General NPI Number Information
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NPI Number | 1912063702
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Entity Type | Organization
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Legal Business Name | BONNIE BRAE
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 3415 VALLEY ROAD
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City | LIBERTY CORNER
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State | NJ
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Zip | 07938
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Country | US
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Telephone | 908-647-0800
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Fax | 908-647-5021
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Provider Business Mailing Address
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Address Line | 3415 VALLEY ROAD PO BOX 825
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City | LIBERTY CORNER
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State | NJ
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Zip | 07938
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Country | US
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Telephone | 908-647-0800
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Fax | 908-647-5021
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Authorized Official
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Title or Position | CEO
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Name | MR. WILLIAM M. POWERS
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Credential |
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Telephone | 908-647-0800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number |
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License Number State | NJ
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