Basic Information
| Provider Information | |||||||||
| NPI: | 1265532436 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPT. VETERANS AFFAIRS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VANJHCS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 52 HERCULES RD | ||||||||
| Address2: | |||||||||
| City: | KENVIL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078472579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739277044 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 151 KNOLLCROFT RD | ||||||||
| Address2: | BLDG. 57 | ||||||||
| City: | LYONS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079395001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086470180 | ||||||||
| FaxNumber: | 9086045850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOORE-MAGEE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9086470180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW, LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 44SC00041400 | NJ | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.