Provider Demographics
NPI:1902043052
Name:PHILIP HOUSE OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:PHILIP HOUSE OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNCKEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCADC
Authorized Official - Phone:732-870-8500
Mailing Address - Street 1:190 CHELSEA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6712
Mailing Address - Country:US
Mailing Address - Phone:732-870-8500
Mailing Address - Fax:732-222-9315
Practice Address - Street 1:190 CHELSEA AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6712
Practice Address - Country:US
Practice Address - Phone:732-870-8500
Practice Address - Fax:732-222-9315
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW HOPE FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-12
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ200011008324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0189324Medicaid
NJ0189201Medicaid