Healthcare Provider Details

I. General information

NPI: 1538551072
Provider Name (Legal Business Name): KING OF HEARTS LIFE ENHANCEMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 BRICK BLVD
BRICK NJ
08723-6089
US

IV. Provider business mailing address

522 BRICK BLVD
BRICK NJ
08723-6089
US

V. Phone/Fax

Practice location:
  • Phone: 732-240-2545
  • Fax: 732-475-6265
Mailing address:
  • Phone: 732-240-2545
  • Fax: 732-475-6265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00034800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00161400
License Number StateNJ

VIII. Authorized Official

Name: DR. TARA MICHELLE KING
Title or Position: DIRECTOR
Credential: LPC, LCADC
Phone: 732-240-2545