Healthcare Provider Details

I. General information

NPI: 1528564358
Provider Name (Legal Business Name): NEW LIFE BEHAVIORAL AND YOUTH DEVELOPMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MORRIS AVE
MONROE LA
71202-2067
US

IV. Provider business mailing address

201 MORRIS AVE
MONROE LA
71202-2067
US

V. Phone/Fax

Practice location:
  • Phone: 318-816-5514
  • Fax: 318-816-5514
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH0012306
License Number StateLA

VIII. Authorized Official

Name: MR. MARK ANTHONY ELEAM
Title or Position: OWNER
Credential:
Phone: 318-600-3962