Healthcare Provider Details

I. General information

NPI: 1053059089
Provider Name (Legal Business Name): LASTING BEHAVIORAL SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 BERLIN RD
GIBBSBORO NJ
08026
US

IV. Provider business mailing address

148 RT 73 STE 3 #166
VOORHEES NJ
08043
US

V. Phone/Fax

Practice location:
  • Phone: 856-739-1013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICOLE ANNE MCCLUSKEY
Title or Position: OWNER/OPERATOR
Credential: M.S., BCBA
Phone: 856-739-1013