Provider Demographics
NPI:1104348911
Name:SOUTH JERSEY BEHAVIORAL HEALTH RESOURCES INCORPORATED
Entity type:Organization
Organization Name:SOUTH JERSEY BEHAVIORAL HEALTH RESOURCES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA WISLON
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:856-361-1120
Mailing Address - Street 1:2500 MCCLELLAN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-0001
Mailing Address - Country:US
Mailing Address - Phone:856-361-1100
Mailing Address - Fax:
Practice Address - Street 1:53 HADDONFIELD RD STE 316
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-4802
Practice Address - Country:US
Practice Address - Phone:856-361-2710
Practice Address - Fax:856-346-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ403010904261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0515752Medicaid
NJ403010904OtherNJ DMHAS