Provider Demographics
NPI:1194946053
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:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:856-361-1133
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:856-361-1133
Mailing Address - Fax:856-488-1450
Practice Address - Street 1:400 MARKET ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102-1526
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:856-541-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2022-07-21
Deactivation Date:2008-05-22
Deactivation Code:
Reactivation Date:2008-07-23
Provider Licenses
StateLicense IDTaxonomies
NJ403010305251T00000X
NJ403010304261QM0801X
NJ403010904261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ406010904OtherDMHAS LICENSE
NJ0041106Medicaid
NJ0515752Medicaid
NJ403010305OtherDMHS LICENSE
NJ7477007Medicaid
NJ7677308OtherWORKFORCE NJ
NJ403010304OtherDMHAS LICENSE
NJ403010904OtherDMHAS LICENSE