Provider Demographics
NPI:1699282525
Name:SURFSIDE RECOVERY SERVICES INC.
Entity type:Organization
Organization Name:SURFSIDE RECOVERY SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCADC, CAS
Authorized Official - Phone:609-709-0244
Mailing Address - Street 1:3 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-1613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 S WEYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:VENTNOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08406-2980
Practice Address - Country:US
Practice Address - Phone:609-709-0245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-31
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00214900101YA0400X
NJ37PC00513700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty