Basic Information
| Provider Information | |||||||||
| NPI: | 1396994588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SERVICE BUREAU OF NEWARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 S ORANGE AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734122056 | ||||||||
| FaxNumber: | 9734843452 | ||||||||
| Practice Location | |||||||||
| Address1: | 379 KEARNY AVE | ||||||||
| Address2: | |||||||||
| City: | KEARNY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070322601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012468077 | ||||||||
| FaxNumber: | 2019556165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2008 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | CHOU | ||||||||
| AuthorizedOfficialFirstName: | CHI SHU | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATION | ||||||||
| AuthorizedOfficialTelephone: | 9734122056 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC, LCADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 2000025-04 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 0597911 | 05 | NJ | MEDICAID |