Provider Demographics
NPI:1912437914
Name:THE WOUNDED HEALER, INC. D/B/A MY FRIENDS HOUSE FAMILY COUNSELING SERV
Entity Type:Organization
Organization Name:THE WOUNDED HEALER, INC. D/B/A MY FRIENDS HOUSE FAMILY COUNSELING SERV
Other - Org Name:MY FRIENDS HOUSE FAMILY COUNSELING SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGUARINA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:856-669-6900
Mailing Address - Street 1:371 GLASSBORO RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08097-1026
Mailing Address - Country:US
Mailing Address - Phone:856-669-6900
Mailing Address - Fax:
Practice Address - Street 1:371 GLASSBORO RD
Practice Address - Street 2:
Practice Address - City:WOODBURY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08097-1026
Practice Address - Country:US
Practice Address - Phone:856-669-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0443867Medicaid