Provider Demographics
NPI:1750435129
Name:EXTRACARE HEALTH SERVICES
Entity type:Organization
Organization Name:EXTRACARE HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:CSW, CDC
Authorized Official - Phone:732-721-0060
Mailing Address - Street 1:141 STATE ROUTE 34
Mailing Address - Street 2:P O BOX 506
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2187
Mailing Address - Country:US
Mailing Address - Phone:732-721-3835
Mailing Address - Fax:239-455-9027
Practice Address - Street 1:141 STATE ROUTE 34
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-2187
Practice Address - Country:US
Practice Address - Phone:732-721-3835
Practice Address - Fax:239-455-9027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPSYD-2136103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty