MEDICARE: LIFEBALANCE COUNSELING AND ART THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	37PC000424400	NJ
2	251S00000X	Community/Behavioral Health Agency	001104	NY

General Provider Information

NPI Number	:	1669750501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBALANCE COUNSELING AND ART THERAPY, LLC

Provider Business Mailing Address
First Line	:	184 S. LIVINGSTON AVE SUITE 9181
Second Line	:
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039
Country	:	US
Telephone Number	:	973-454-6087
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 S LIVINGSTON AVE STE 205
Second Line	:
City	:	LIVINGSTON
State	:	NJ
Zip	:	07039-3929
Country	:	US
Telephone Number	:	973-454-6087
Fax Number	:

Authorized Official
Title or Position	:	OWNER, OPERATOR
Name	:	MS. RITA KLACHKIN
Credential	:	LPC, LCAT
Telephone Number	:	973-454-6087

Provider Enumeration Date	:	07/26/2011
Last Update Date	:	07/26/2011

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