Provider Demographics
NPI:1710400106
Name:UNICORN SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:UNICORN SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONDAY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-278-5188
Mailing Address - Street 1:22 VALLEY FORGE DR
Mailing Address - Street 2:
Mailing Address - City:SWEDESBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-4230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 VALLEY FORGE DR
Practice Address - Street 2:
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-4230
Practice Address - Country:US
Practice Address - Phone:856-278-5188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3104A0630X, 311Z00000X, 320600000X, 320700000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities