Provider Demographics
NPI:1972081537
Name:IMPACT ENDEAVORS LLC
Entity type:Organization
Organization Name:IMPACT ENDEAVORS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:856-229-2032
Mailing Address - Street 1:554 CAPRI CT
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-3044
Mailing Address - Country:US
Mailing Address - Phone:856-229-2032
Mailing Address - Fax:
Practice Address - Street 1:44 COOPER ST STE 108
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-4642
Practice Address - Country:US
Practice Address - Phone:856-229-2032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC0130790261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)