Provider Demographics
NPI:1659822559
Name:SPECIAL HOMES OF NEW JERSEY
Entity Type:Organization
Organization Name:SPECIAL HOMES OF NEW JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKEON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:973-886-1953
Mailing Address - Street 1:56 HINCHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2141
Mailing Address - Country:US
Mailing Address - Phone:973-886-1953
Mailing Address - Fax:973-664-1795
Practice Address - Street 1:74 VILLAGE GRN APT 40R
Practice Address - Street 2:
Practice Address - City:BUDD LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07828-1379
Practice Address - Country:US
Practice Address - Phone:973-886-1953
Practice Address - Fax:973-664-1795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0530549Medicaid