Provider Demographics
NPI:1780291542
Name:BONNIE BRAE
Entity type:Organization
Organization Name:BONNIE BRAE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:RIEGER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:908-647-4719
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:LIBERTY CORNER
Practice Address - State:NJ
Practice Address - Zip Code:07938
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:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1831522523Medicaid
NJ1245689686Medicaid
NJ1447885520Medicaid
NJ1497152961Medicaid
NJ1003081605Medicaid
NJ1235405689Medicaid
NJ1912063702Medicaid
NJ1508220922Medicaid
NJ183448414Medicaid