Provider Demographics
NPI:1780806083
Name:MARYVILLE, INC
Entity type:Organization
Organization Name:MARYVILLE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCADC
Authorized Official - Phone:856-227-2717
Mailing Address - Street 1:707 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1605
Mailing Address - Country:US
Mailing Address - Phone:856-863-3913
Mailing Address - Fax:856-863-3917
Practice Address - Street 1:707 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-1605
Practice Address - Country:US
Practice Address - Phone:856-863-3913
Practice Address - Fax:856-863-3917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ23032261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7632304Medicaid