Provider Demographics
NPI:1871254409
Name:METAMORPHOSIS TRANSITIONAL LIVING
Entity Type:Organization
Organization Name:METAMORPHOSIS TRANSITIONAL LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:MARETTA
Authorized Official - Middle Name:LAJAUNE
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:EDM, MSW
Authorized Official - Phone:201-255-7348
Mailing Address - Street 1:100 SELVAGE AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4819
Mailing Address - Country:US
Mailing Address - Phone:201-255-7348
Mailing Address - Fax:201-255-7352
Practice Address - Street 1:241 HUDSON ST STE 133
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-6708
Practice Address - Country:US
Practice Address - Phone:201-255-7348
Practice Address - Fax:201-255-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH60825187351722OtherNJ DRIVERS LICENSE