Provider Demographics
NPI:1073735460
Name:BEACON BEHAVIORAL HEALTH II
Entity Type:Organization
Organization Name:BEACON BEHAVIORAL HEALTH II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:DORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LCADC
Authorized Official - Phone:856-256-8935
Mailing Address - Street 1:20 NURSERY CT
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028
Mailing Address - Country:US
Mailing Address - Phone:856-256-8935
Mailing Address - Fax:
Practice Address - Street 1:110 MARTER AVE STE 406
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3124
Practice Address - Country:US
Practice Address - Phone:856-256-8935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2344668OtherCIGNA BEHAVIORAL HEALTH