Organization
THE COMMUNITY YMCA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LEEANN WAGNER LPC, LCADC (OUTPATIENT DIRECTOR)
73229209040
Entity
Organization
Contact information
Practice address
376 MAPLE PL, KEYPORT, NJ 07735-1148
(732) 290-9040
(732) 566-0433
Mailing address
166 MAIN ST, MATAWAN, NJ 07747-3104
(732) 290-9040
(732) 566-0433
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
100052305
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0410152
—
NJ
Enumeration date
02/08/2017
Last updated
02/08/2017
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