Provider Demographics
NPI:1912232869
Name:WELLESLEY HEALTHCARE GROUP
Entity Type:Organization
Organization Name:WELLESLEY HEALTHCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARLON
Authorized Official - Middle Name:WELLESLEY
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-726-2265
Mailing Address - Street 1:529 BUTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4945
Mailing Address - Country:US
Mailing Address - Phone:732-333-0197
Mailing Address - Fax:732-333-0198
Practice Address - Street 1:16 W MAIN ST
Practice Address - Street 2:FL 2
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2210
Practice Address - Country:US
Practice Address - Phone:732-333-0197
Practice Address - Fax:732-333-0198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-10
Last Update Date:2009-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children