Healthcare Provider Details

I. General information

NPI: 1780498311
Provider Name (Legal Business Name): NEW LIFE ADVANTAGE SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TILLARY ST
BROOKLYN NY
11201-3010
US

IV. Provider business mailing address

254 CLINTON AVE APT 2
JERSEY CITY NJ
07304-1608
US

V. Phone/Fax

Practice location:
  • Phone: 938-888-4697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: WADE PHILLIPS
Title or Position: MANAGER
Credential:
Phone: 938-888-4697