Provider Demographics
NPI:1912772633
Name:INDIVIDUALIZED SUPPORTS
Entity Type:Organization
Organization Name:INDIVIDUALIZED SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:973-647-4980
Mailing Address - Street 1:666 PAXSON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1143
Mailing Address - Country:US
Mailing Address - Phone:973-647-4980
Mailing Address - Fax:
Practice Address - Street 1:666 PAXSON AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-1143
Practice Address - Country:US
Practice Address - Phone:973-647-4980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty