Provider Demographics
NPI:1043735699
Name:TEACHABLE MOMENTS OF NJ
Entity Type:Organization
Organization Name:TEACHABLE MOMENTS OF NJ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:POTENZA
Authorized Official - Suffix:
Authorized Official - Credentials:TOH
Authorized Official - Phone:201-478-1547
Mailing Address - Street 1:PO BOX 1122
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-7122
Mailing Address - Country:US
Mailing Address - Phone:201-478-1547
Mailing Address - Fax:
Practice Address - Street 1:41 FAIRMOUNT AVE APT 8B
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4747
Practice Address - Country:US
Practice Address - Phone:201-478-1547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ00370093106S00000X
NJ00375093261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty