Provider Demographics
NPI:1730671686
Name:WILLOWGLEN ACADEMY - NEW JERSEY. INC.
Entity Type:Organization
Organization Name:WILLOWGLEN ACADEMY - NEW JERSEY. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-579-3700
Mailing Address - Street 1:8 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3400
Mailing Address - Country:US
Mailing Address - Phone:973-579-3700
Mailing Address - Fax:973-579-1786
Practice Address - Street 1:8 WILSON DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3400
Practice Address - Country:US
Practice Address - Phone:973-579-3700
Practice Address - Fax:973-579-1786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CARE SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0479896Medicaid