Provider Demographics
NPI:1003014663
Name:SOUTH BROAD STREET COUNSELING SERVICES INC
Entity Type:Organization
Organization Name:SOUTH BROAD STREET COUNSELING SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:H
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:609-394-8000
Mailing Address - Street 1:1418 SOUTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08610
Mailing Address - Country:US
Mailing Address - Phone:609-394-8000
Mailing Address - Fax:
Practice Address - Street 1:1418 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08610
Practice Address - Country:US
Practice Address - Phone:609-394-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000283261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0006033OtherSAI PROVIDER NUMBER
NJ8937401Medicaid