Provider Demographics
NPI:1689883498
Name:ST. TIMOTHY'S GROUP HOME FOR BOYS
Entity Type:Organization
Organization Name:ST. TIMOTHY'S GROUP HOME FOR BOYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-621-2273
Mailing Address - Street 1:399 HEYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-2006
Mailing Address - Country:US
Mailing Address - Phone:973-673-4562
Mailing Address - Fax:973-673-3238
Practice Address - Street 1:25 JAMES ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2001
Practice Address - Country:US
Practice Address - Phone:973-621-2273
Practice Address - Fax:973-621-7259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8488509Medicaid