Provider Demographics
NPI:1164684148
Name:WILLOWGLEN ACADEMY-NJ INC
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY-NJ INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR OF FISCAL AFFAIR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-579-3700
Mailing Address - Street 1:8 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3400
Mailing Address - Country:US
Mailing Address - Phone:973-579-3700
Mailing Address - Fax:973-579-1786
Practice Address - Street 1:8 WILSON DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3400
Practice Address - Country:US
Practice Address - Phone:973-579-3700
Practice Address - Fax:973-579-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8374104Medicaid