=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538997291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYFE GLOBAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2024
-----------------------------------------------------
Last Update Date | 07/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 E HAZELWOOD AVE
-----------------------------------------------------
City | RAHWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07065-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-470-4283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 HAWTHORNE LN
-----------------------------------------------------
City | WILLINGBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08046-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-470-4283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. SAMUEL C WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-470-4283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------