Provider Demographics
NPI:1598270795
Name:FAMILY INNOVATION AND CONSULTATION
Entity Type:Organization
Organization Name:FAMILY INNOVATION AND CONSULTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SCHAUNE
Authorized Official - Middle Name:DAYDREA
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:917-288-1100
Mailing Address - Street 1:62 AMBER DR
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-3588
Mailing Address - Country:US
Mailing Address - Phone:917-288-1100
Mailing Address - Fax:
Practice Address - Street 1:62 AMBER DR
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3588
Practice Address - Country:US
Practice Address - Phone:917-288-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-10
Last Update Date:2017-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05689700251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health