Provider Demographics
NPI:1710411632
Name:CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.
Entity Type:Organization
Organization Name:CENTER FOR FAMILY SUPPORT, NEW JERSEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZOCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-629-7939
Mailing Address - Street 1:333 7TH AVE FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 TEXAS RD
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3904
Practice Address - Country:US
Practice Address - Phone:732-967-6610
Practice Address - Fax:732-967-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJGH2155320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0471224Medicaid