Provider Demographics
NPI:1992933634
Name:XANADU BEHAVIOR THERAPY
Entity type:Organization
Organization Name:XANADU BEHAVIOR THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROELING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-242-3322
Mailing Address - Street 1:615 LACEY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-2200
Mailing Address - Country:US
Mailing Address - Phone:609-242-3322
Mailing Address - Fax:609-242-3333
Practice Address - Street 1:615 LACEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2200
Practice Address - Country:US
Practice Address - Phone:609-242-3322
Practice Address - Fax:609-242-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0-06-2178103K00000X
NJ44SL04976200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty