Provider Demographics
NPI:1912316639
Name:GENUINE ME OF SOUTH JERSEY INC
Entity Type:Organization
Organization Name:GENUINE ME OF SOUTH JERSEY INC
Other - Org Name:GENUINE ME LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:FADOOL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:609-828-0097
Mailing Address - Street 1:3 CRANBURY HILL CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-4849
Mailing Address - Country:US
Mailing Address - Phone:609-828-0097
Mailing Address - Fax:856-802-0885
Practice Address - Street 1:111 CHURCH RD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:609-828-0097
Practice Address - Fax:856-802-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-06
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055766001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450088977OtherNEW JERSERY CERTIFICATE OF INC (PROFIT)
NJ0450088977OtherNEW JERSERY CERTIFICATE OF INC (PROFIT)