Provider Demographics
NPI:1912063702
Name:BONNIE BRAE
Entity Type:Organization
Organization Name:BONNIE BRAE
Other - Org Name:BONNIE BRAE RESIDENTIAL TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-647-0800
Mailing Address - Street 1:3415 VALLEY ROAD
Mailing Address - Street 2:PO BOX 825
Mailing Address - City:LIBERTY CORNER
Mailing Address - State:NJ
Mailing Address - Zip Code:07938
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:2006-12-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0032506Medicaid
NJ0073661Medicaid
NJ8372403Medicaid