Provider Demographics
NPI:1437378379
Name:SOUTH JERSEY BEHAVIORAL HEALTH RESOURCES INCORPORATED
Entity Type:Organization
Organization Name:SOUTH JERSEY BEHAVIORAL HEALTH RESOURCES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:856-541-1700
Mailing Address - Street 1:2500 MCCLELLAN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-0001
Mailing Address - Country:US
Mailing Address - Phone:856-361-1100
Mailing Address - Fax:856-488-1450
Practice Address - Street 1:212 MADISON AVE E
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:NJ
Practice Address - Zip Code:08049-1409
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:856-309-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2022-07-21
Deactivation Date:2008-05-22
Deactivation Code:
Reactivation Date:2008-07-23
Provider Licenses
StateLicense IDTaxonomies
NJ403010205251S00000X
NJ403010348253Z00000X
NJ40301D050041320800000X
NJ40301D050240320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ403010205OtherDMHS
NJ0083909Medicaid
NJ0548481Medicaid
NJ40301D050041OtherDMHAS LICENSE
NJ7477007Medicaid
NJ403010348OtherDMHAS LICENSE
NJ0523780Medicaid
NJ40301D050240OtherDMHAS