Provider Demographics
NPI:1972715142
Name:TRI COUNTY PASSAIC TEEN CENTER
Entity type:Organization
Organization Name:TRI COUNTY PASSAIC TEEN CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RASHEED
Authorized Official - Middle Name:I
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MSW
Authorized Official - Phone:973-473-5755
Mailing Address - Street 1:228 HOPE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:973-473-5755
Mailing Address - Fax:
Practice Address - Street 1:228 HOPE AVENUE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-473-5755
Practice Address - Fax:973-470-8999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8373507Medicaid
NJ8373507Medicaid