Provider Demographics
NPI:1093970741
Name:GOOD FRIENDS OF CHILDREN WITH CHILDHOOD DEVELOPMENTAL DISABILITIES
Entity Type:Organization
Organization Name:GOOD FRIENDS OF CHILDREN WITH CHILDHOOD DEVELOPMENTAL DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PATT
Authorized Official - Middle Name:OLUWASINA
Authorized Official - Last Name:OGUNWALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-204-2210
Mailing Address - Street 1:PO BOX 8774
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-0774
Mailing Address - Country:US
Mailing Address - Phone:973-204-2210
Mailing Address - Fax:973-991-1257
Practice Address - Street 1:39 WAINWRIGHT ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-1333
Practice Address - Country:US
Practice Address - Phone:973-204-2210
Practice Address - Fax:973-991-1257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0161616251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0161616Medicaid