Provider Demographics
NPI:1205957917
Name:MCG BH PACT PROGRAM
Entity type:Organization
Organization Name:MCG BH PACT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:O
Authorized Official - Last Name:EZEALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-466-1351
Mailing Address - Street 1:1 CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-5280
Mailing Address - Country:US
Mailing Address - Phone:732-650-1401
Mailing Address - Fax:
Practice Address - Street 1:269 OLIVER ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-2507
Practice Address - Country:US
Practice Address - Phone:973-466-1351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR09838600251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management