Healthcare Provider Details

I. General information

NPI: 1922729375
Provider Name (Legal Business Name): STEAM 4 URBN YOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BROAD ST # 323
NEWARK NJ
07102-2760
US

IV. Provider business mailing address

8 LOMBARDY ST # 176
NEWARK NJ
07102-3210
US

V. Phone/Fax

Practice location:
  • Phone: 678-651-9778
  • Fax:
Mailing address:
  • Phone: 678-651-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: FALLON DAVIS
Title or Position: CEO/FOUNDER
Credential: M.ED
Phone: 678-651-9778