Provider Demographics
NPI:1003049685
Name:LYFES NEW DIRECTION
Entity Type:Organization
Organization Name:LYFES NEW DIRECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-721-4261
Mailing Address - Street 1:1001 S MARSHALL ST # 65
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5852
Mailing Address - Country:US
Mailing Address - Phone:336-721-4261
Mailing Address - Fax:336-721-4265
Practice Address - Street 1:1001 S MARSHALL ST # 65
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5852
Practice Address - Country:US
Practice Address - Phone:336-721-4261
Practice Address - Fax:336-721-4265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC2009212000082251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health