MEDICARE: C-LINE COMMUNITY OUTREACH SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00116800	NJ
2	101YM0800X	Mental Health Counselor	44SC05375200	NJ
3	261QM1300X	Multi-Specialty Clinic/Center	2000071	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336431675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C-LINE COMMUNITY OUTREACH SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 15802
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-0802
Country	:	US
Telephone Number	:	201-200-1965
Fax Number	:	201-200-1826

Provider Business Practice Location Address
First Line	:	110 MARTIN LUTHER KING JR DR
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-3168
Country	:	US
Telephone Number	:	201-200-1965
Fax Number	:	201-200-1826

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. CAROLINE NELSON
Credential	:
Telephone Number	:	201-200-1965

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	05/21/2014

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Directions to “C-LINE COMMUNITY OUTREACH SERVICES ” Practice Location

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