Healthcare Provider Details

I. General information

NPI: 1013774082
Provider Name (Legal Business Name): LEVELED UP REENTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7821 S PARK AVE
TACOMA WA
98408-5314
US

IV. Provider business mailing address

4227 S MERIDIAN STE D421
PUYALLUP WA
98373-3603
US

V. Phone/Fax

Practice location:
  • Phone: 253-878-8888
  • Fax:
Mailing address:
  • Phone: 253-878-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: LATANISHA BOOKER
Title or Position: CEO
Credential:
Phone: 253-878-8888