Provider Demographics
NPI:1245689686
Name:BONNIE BRAE
Entity type:Organization
Organization Name:BONNIE BRAE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-542-2736
Mailing Address - Street 1:PO BOX 825
Mailing Address - Street 2:
Mailing Address - City:LIBERTY CORNER
Mailing Address - State:NJ
Mailing Address - Zip Code:07938-0825
Mailing Address - Country:US
Mailing Address - Phone:908-647-0800
Mailing Address - Fax:908-647-5021
Practice Address - Street 1:3415 VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:BAKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-2655
Practice Address - Country:US
Practice Address - Phone:908-647-0800
Practice Address - Fax:908-647-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1060320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8372403Medicaid