Provider Demographics
NPI:1932523883
Name:PAPA GANACHE PROJECT, LLC
Entity Type:Organization
Organization Name:PAPA GANACHE PROJECT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SIROTI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-770-0428
Mailing Address - Street 1:106 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2656
Mailing Address - Country:US
Mailing Address - Phone:732-217-1750
Mailing Address - Fax:732-217-1749
Practice Address - Street 1:106 MAIN ST
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-2656
Practice Address - Country:US
Practice Address - Phone:732-217-1750
Practice Address - Fax:732-217-1749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 104100000X, 106H00000X
NJ1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0252069Medicaid