Provider Demographics
NPI:1538659511
Name:YMCA OF GREATER MONMOUTH COUNTY
Entity Type:Organization
Organization Name:YMCA OF GREATER MONMOUTH COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-290-9040
Mailing Address - Street 1:166 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3104
Mailing Address - Country:US
Mailing Address - Phone:732-290-9040
Mailing Address - Fax:732-566-0433
Practice Address - Street 1:60 WALNUT ST
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-5265
Practice Address - Country:US
Practice Address - Phone:732-290-9040
Practice Address - Fax:732-566-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1000054504251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0632562Medicaid