Provider Demographics
NPI:1306968946
Name:SOMERSET HOME FOR TEMPORARILY DISPLACED CHILDREN
Entity type:Organization
Organization Name:SOMERSET HOME FOR TEMPORARILY DISPLACED CHILDREN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FETZKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-526-6605
Mailing Address - Street 1:49 BRAHMA AVE
Mailing Address - Street 2:P.O. BOX 6781
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2758
Mailing Address - Country:US
Mailing Address - Phone:908-526-6605
Mailing Address - Fax:908-526-4433
Practice Address - Street 1:16 4TH AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-2004
Practice Address - Country:US
Practice Address - Phone:908-526-6686
Practice Address - Fax:908-526-4242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5070322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8374708Medicaid