Healthcare Provider Details

I. General information

NPI: 1992081517
Provider Name (Legal Business Name): REBUILD YOUR LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 GLASSBORO RD SUITE 104, FIRST FLOOR
WOODBURY HTS NJ
08097-1400
US

IV. Provider business mailing address

488 GLASSBORO RD SUITE 104, FIRST FLOOR
WOODBURY HTS NJ
08097-1400
US

V. Phone/Fax

Practice location:
  • Phone: 856-904-8888
  • Fax: 856-853-0024
Mailing address:
  • Phone: 856-904-8888
  • Fax: 856-853-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1632435
License Number StateNJ

VIII. Authorized Official

Name: MRS. KATHLEEN ORITI
Title or Position: OWNER
Credential:
Phone: 856-904-8888