Healthcare Provider Details

I. General information

NPI: 1356855175
Provider Name (Legal Business Name): GUIDED LIFE STRUCTURES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 VETERANS MEMORIAL DR E STE 205
SOMERVILLE NJ
08876-2949
US

IV. Provider business mailing address

75 VETERANS MEMORIAL DR E STE 205
SOMERVILLE NJ
08876-2949
US

V. Phone/Fax

Practice location:
  • Phone: 908-704-0011
  • Fax: 908-704-0711
Mailing address:
  • Phone: 908-704-0011
  • Fax: 908-704-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2000133
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number2000133
License Number StateNJ

VIII. Authorized Official

Name: EILEEN OERTEL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 908-704-0011