Provider Inquiry Form Provider Inquiry Form Step 1 of 2 50% FacilityAddress Phone NumberFaxTINEmailCountyAtlantic CountyBergen CountyBurlington CountyCamden CountyCape May CountyCumberland CountyEssex CountyGloucester CountyHudson CountyHunterdon CountyMercer CountyMiddlesex CountyMonmouth CountyMorris CountyOcean CountyPassaic CountySalem CountySomerset CountySussex CountyUnion CountyWarren CountyTotal number of bedsMemory unit bedsOtherOwnership Information Please list name(s) of those owning 5% & greater interest.Special Clinical Programs Awards & Certifications Additional Information/Comments Captcha