=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952088106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARECONNECT SUPPORT AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2023
-----------------------------------------------------
Last Update Date | 06/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 DILLION CT
-----------------------------------------------------
City | NORTH BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08902-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-257-1057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 DILLION CT
-----------------------------------------------------
City | NORTH BRUNSWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08902-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-257-1057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE MANAGER
-----------------------------------------------------
Name | FATMATA BARRIE
-----------------------------------------------------
Credential | MSC., PMP
-----------------------------------------------------
Telephone | 908-257-1057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------