Provider Demographics
NPI:1073807558
Name:INTEGRAL DEVELOPMENT THERAPIES, LLC
Entity Type:Organization
Organization Name:INTEGRAL DEVELOPMENT THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-241-3029
Mailing Address - Street 1:108 MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:OCEANPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07757-1030
Mailing Address - Country:US
Mailing Address - Phone:732-241-3029
Mailing Address - Fax:732-865-7772
Practice Address - Street 1:108 MAIN ST
Practice Address - Street 2:SUITE #5
Practice Address - City:OCEANPORT
Practice Address - State:NJ
Practice Address - Zip Code:07757-1030
Practice Address - Country:US
Practice Address - Phone:732-241-3029
Practice Address - Fax:732-865-7772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05358800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1386780898OtherNPI INDIVIDUAL