Provider Demographics
NPI:1669663746
Name:CHILDRENS INTENSIVE IN COMMUNITY PROGRAM
Entity Type:Organization
Organization Name:CHILDRENS INTENSIVE IN COMMUNITY PROGRAM
Other - Org Name:NON PROFIT ORGANIZATION
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOMAH
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-829-9440
Mailing Address - Street 1:101 RT 130 S
Mailing Address - Street 2:GRANT BUILDING SUITE 440
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-2845
Mailing Address - Country:US
Mailing Address - Phone:856-829-9440
Mailing Address - Fax:856-829-9444
Practice Address - Street 1:101 RT 130 S
Practice Address - Street 2:GRANT BUILDING SUITE 440
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-2845
Practice Address - Country:US
Practice Address - Phone:856-829-9440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC003757101YM0800X
NJ445L051454001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty