Provider Demographics
NPI:1770295941
Name:ICBH
Entity type:Organization
Organization Name:ICBH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR, SUPERVISOR, EDUCATOR
Authorized Official - Prefix:
Authorized Official - First Name:CLARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIGAN ATTARA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC, LCADC, ACS
Authorized Official - Phone:732-668-4460
Mailing Address - Street 1:200 VILLAGE CENTER DR
Mailing Address - Street 2:# 6722
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-1702
Mailing Address - Country:US
Mailing Address - Phone:732-668-4460
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE AVE STE WB2
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1736
Practice Address - Country:US
Practice Address - Phone:732-668-4460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450874979Other0450874979