Provider Demographics
NPI:1639882699
Name:FRESH START OUTPATIENT CARE SERVICES
Entity Type:Organization
Organization Name:FRESH START OUTPATIENT CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:JUANIQUE
Authorized Official - Last Name:LARK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:856-220-7035
Mailing Address - Street 1:38 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-1635
Mailing Address - Country:US
Mailing Address - Phone:856-220-7035
Mailing Address - Fax:
Practice Address - Street 1:600 SOMERDALE RD STE 101
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1858
Practice Address - Country:US
Practice Address - Phone:856-220-7035
Practice Address - Fax:856-595-9377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health