Provider Demographics
NPI:1528881836
Name:MENTAL HEALTH THERAPEUTIC BEHAVIORAL SUPPORTS & DEV. DIS., LLC
Entity type:Organization
Organization Name:MENTAL HEALTH THERAPEUTIC BEHAVIORAL SUPPORTS & DEV. DIS., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:073-762-2020
Mailing Address - Street 1:60 N WYOMING AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1526
Mailing Address - Country:US
Mailing Address - Phone:973-762-2020
Mailing Address - Fax:973-762-2021
Practice Address - Street 1:81 NORTHFIELD AVE STE 106
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5343
Practice Address - Country:US
Practice Address - Phone:973-762-2020
Practice Address - Fax:973-762-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health