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General NPI Number Information
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NPI Number | 1780498311
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Entity Type | Organization
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Legal Business Name | NEW LIFE ADVANTAGE SUPPORT
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Dates
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Enumeration Date | 02/04/2025
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 200 TILLARY ST
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City | BROOKLYN
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State | NY
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Zip | 11201-3010
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Country | US
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Telephone | 938-888-4697
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Fax |
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Provider Business Mailing Address
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Address Line | 254 CLINTON AVE APT 2
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City | JERSEY CITY
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State | NJ
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Zip | 07304-1608
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | WADE PHILLIPS
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Credential |
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Telephone | 938-888-4697
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0807X
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Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number |
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License Number State |
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