Healthcare Provider Details

I. General information

NPI: 1184308793
Provider Name (Legal Business Name): LD BEHAVIORAL AND SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W SOUTH ORANGE AVE
SOUTH ORANGE NJ
07079-1730
US

IV. Provider business mailing address

382 VALLEY ST
SOUTH ORANGE NJ
07079-2806
US

V. Phone/Fax

Practice location:
  • Phone: 201-486-3367
  • Fax: 973-378-9525
Mailing address:
  • Phone: 201-486-3367
  • Fax: 973-378-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. EDNA YOLANDA LEE
Title or Position: CEO/OWNER
Credential: REGISTERED NURSE
Phone: 201-486-3367