Provider Demographics
NPI:1104512839
Name:PAPOOSE BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:PAPOOSE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOLANLE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUGBILE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:718-775-8507
Mailing Address - Street 1:105 DANIEL AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2718
Mailing Address - Country:US
Mailing Address - Phone:718-775-8507
Mailing Address - Fax:
Practice Address - Street 1:105 DANIEL AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2718
Practice Address - Country:US
Practice Address - Phone:718-775-8507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health