Healthcare Provider Details

I. General information

NPI: 1902554298
Provider Name (Legal Business Name): UPLIFT BEHAVIORAL HEALTH NJ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 CLINTON STREET UNIT 2B
HOBOKEN NJ
07030
US

IV. Provider business mailing address

4417 W KENSINGTON AVE
TAMPA FL
33629-8339
US

V. Phone/Fax

Practice location:
  • Phone: 202-932-7607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KYLE TALCOTT
Title or Position: PARTNER
Credential:
Phone: 904-294-5194