MEDICARE: KALEIDOSCOPE DISABILITIES INC

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	104100000X	Social Worker	44SL05576000	NJ

General Provider Information

NPI Number	:	1710282389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALEIDOSCOPE DISABILITIES INC

Provider Business Mailing Address
First Line	:	810 BELMONT AVE
Second Line	:	2ND FLOOR SUITE 202
City	:	NORTH HALEDON
State	:	NJ
Zip	:	07508-2357
Country	:	US
Telephone Number	:	973-427-4251
Fax Number	:	888-262-0085

Provider Business Practice Location Address
First Line	:	810 BELMONT AVE
Second Line	:	2ND FLOOR SUITE 202
City	:	NORTH HALEDON
State	:	NJ
Zip	:	07508-2357
Country	:	US
Telephone Number	:	973-427-4251
Fax Number	:	888-262-0085

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. QUINCEY HOLLOWAY
Credential	:	LSW
Telephone Number	:	973-427-4251

Provider Enumeration Date	:	01/12/2011
Last Update Date	:	01/12/2011

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