Provider Demographics
NPI:1902132111
Name:THE DEVEREUX FOUNDATION
Entity type:Organization
Organization Name:THE DEVEREUX FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NATIONAL DIRECTOR AR
Authorized Official - Prefix:MS
Authorized Official - First Name:FRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-542-3084
Mailing Address - Street 1:286 MANTUA GROVE RD
Mailing Address - Street 2:BUILDING 4
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08066-1738
Mailing Address - Country:US
Mailing Address - Phone:856-599-6400
Mailing Address - Fax:856-599-6401
Practice Address - Street 1:286 MANTUA GROVE RD
Practice Address - Street 2:BUILDING 4
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08066-1738
Practice Address - Country:US
Practice Address - Phone:856-599-6400
Practice Address - Fax:856-599-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0203246Medicaid