Provider Demographics
NPI:1235405689
Name:BONNIE BRAE
Entity Type:Organization
Organization Name:BONNIE BRAE
Other - Org Name:BONNIE BRAE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOUVELEKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-647-4702
Mailing Address - Street 1:PO BOX 825
Mailing Address - Street 2:
Mailing Address - City:LIBERTY CORNER
Mailing Address - State:NJ
Mailing Address - Zip Code:07938-0825
Mailing Address - Country:US
Mailing Address - Phone:908-647-4702
Mailing Address - Fax:908-647-5021
Practice Address - Street 1:3415 VALLEY RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-2655
Practice Address - Country:US
Practice Address - Phone:908-647-4702
Practice Address - Fax:908-647-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0267091322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0267091Medicaid