Provider Demographics
NPI:1669910725
Name:MAKING A DIFFERENCE IN TEENS AND YOUNG ADULTS
Entity type:Organization
Organization Name:MAKING A DIFFERENCE IN TEENS AND YOUNG ADULTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LASHUN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CSW
Authorized Official - Phone:973-652-4199
Mailing Address - Street 1:1035 SANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1946
Mailing Address - Country:US
Mailing Address - Phone:973-652-4199
Mailing Address - Fax:
Practice Address - Street 1:1035 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1946
Practice Address - Country:US
Practice Address - Phone:973-652-4199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management