MEDICARE: EASTER SEALS NEW JERSEY,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	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00041500	NJ
2	1041C0700X	Clinical Social Worker	44SC04936900	NJ

General Provider Information

NPI Number	:	1760813661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTER SEALS NEW JERSEY,INC

Provider Business Mailing Address
First Line	:	25 KENNEDY BLVD STE 600
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-1262
Country	:	US
Telephone Number	:	732-905-5324
Fax Number	:	732-257-7373

Provider Business Practice Location Address
First Line	:	25 KENNEDY BLVD STE 600
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-1262
Country	:	US
Telephone Number	:	732-905-5324
Fax Number	:	732-257-7373

Authorized Official
Title or Position	:	CFO
Name	:	CHERYL MARKS YOUNG
Credential	:
Telephone Number	:	732-257-6662

Provider Enumeration Date	:	12/03/2013
Last Update Date	:	12/03/2013

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