Provider Demographics
NPI:1861989436
Name:WILLOWGLEN ACADEMY - NEW JERSEY. INC.
Entity type:Organization
Organization Name:WILLOWGLEN ACADEMY - NEW JERSEY. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIONE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-579-3700
Mailing Address - Street 1:8 WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871
Mailing Address - Country:US
Mailing Address - Phone:973-579-3700
Mailing Address - Fax:973-579-1786
Practice Address - Street 1:4 CENTER STREET
Practice Address - Street 2:APT 36
Practice Address - City:SUSSEX
Practice Address - State:NJ
Practice Address - Zip Code:07461
Practice Address - Country:US
Practice Address - Phone:973-579-3700
Practice Address - Fax:973-579-1786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CARE SYSTEMS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child