Provider Demographics
NPI:1164006797
Name:BOYS & GIRLS CLUB OF NEWARK WELLNESS CENTER
Entity Type:Organization
Organization Name:BOYS & GIRLS CLUB OF NEWARK WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMMUNITY WELLNESS
Authorized Official - Prefix:
Authorized Official - First Name:GARDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEIGHTS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:646-236-5695
Mailing Address - Street 1:1 AVON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-2801
Mailing Address - Country:US
Mailing Address - Phone:973-242-1200
Mailing Address - Fax:
Practice Address - Street 1:1 AVON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-2801
Practice Address - Country:US
Practice Address - Phone:973-242-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOYS & GIRLS CLUB OF NEWARK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-10
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)