Provider Demographics
NPI:1740596568
Name:MENTOR ABI
Entity Type:Organization
Organization Name:MENTOR ABI
Other - Org Name:NEURORESTORATIVE NEW JERSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-626-1444
Mailing Address - Street 1:10150 HIGHLAND MANOR DR STE 140
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9712
Mailing Address - Country:US
Mailing Address - Phone:813-626-1444
Mailing Address - Fax:813-902-6719
Practice Address - Street 1:2000 CRAWFORD PL STE 700
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3950
Practice Address - Country:US
Practice Address - Phone:813-626-1444
Practice Address - Fax:813-621-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ283X00000X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0256625Medicaid