Healthcare Provider Details

I. General information

NPI: 1538997291
Provider Name (Legal Business Name): LYFE GLOBAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 E HAZELWOOD AVE
RAHWAY NJ
07065-3813
US

IV. Provider business mailing address

15 HAWTHORNE LN
WILLINGBORO NJ
08046-1717
US

V. Phone/Fax

Practice location:
  • Phone: 609-470-4283
  • Fax:
Mailing address:
  • Phone: 609-470-4283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL C WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 609-470-4283