Provider Demographics
NPI:1720314024
Name:UNITY PLACE DAS PROGRAM
Entity Type:Organization
Organization Name:UNITY PLACE DAS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MHS,LCADC,LPC
Authorized Official - Phone:856-424-4142
Mailing Address - Street 1:1 KEYSTONE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1600
Mailing Address - Country:US
Mailing Address - Phone:856-424-4142
Mailing Address - Fax:
Practice Address - Street 1:1 KEYSTONE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-1600
Practice Address - Country:US
Practice Address - Phone:856-424-4142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10053-01-05251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ251S00000XMedicaid