Healthcare Provider Details

I. General information

NPI: 1861214850
Provider Name (Legal Business Name): NEW LIFE 360 INC-RIVERVIEW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13927 SMILING DAISY PL
RIVERVIEW FL
33579
US

IV. Provider business mailing address

13927 SMILING DAISY PL
RIVERVIEW FL
33579
US

V. Phone/Fax

Practice location:
  • Phone: 734-890-9291
  • Fax:
Mailing address:
  • Phone: 734-890-9291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMACA BRADLEY
Title or Position: CLINICAL THERAPIST
Credential: LCSW
Phone: 734-890-9291