Healthcare Provider Details

I. General information

NPI: 1417444076
Provider Name (Legal Business Name): LEADING YOUTH THROUGH EXPERIENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ARROWHEAD CT
FREEHOLD NJ
07728-9577
US

IV. Provider business mailing address

2 ARROWHEAD CT
FREEHOLD NJ
07728-9577
US

V. Phone/Fax

Practice location:
  • Phone: 732-458-3201
  • Fax: 732-458-3269
Mailing address:
  • Phone: 732-458-3201
  • Fax: 732-458-3269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name: JASON MARK ROSENBERG
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential:
Phone: 732-458-3201