Provider Demographics
NPI:1841326931
Name:BEACH BUNGALO LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:BEACH BUNGALO LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-557-0354
Mailing Address - Street 1:712 E LONG BRANCH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721
Mailing Address - Country:US
Mailing Address - Phone:732-557-0354
Mailing Address - Fax:732-286-4334
Practice Address - Street 1:892 COMMON WAY
Practice Address - Street 2:SUITE H
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753
Practice Address - Country:US
Practice Address - Phone:732-557-0354
Practice Address - Fax:732-286-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103T00000X
NJ44SC052019001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty