Provider Demographics
NPI:1164155305
Name:SELFF RECOVERY COACHING
Entity Type:Organization
Organization Name:SELFF RECOVERY COACHING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLIE
Authorized Official - Middle Name:YOLANDER
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LP-MHC,CASAC
Authorized Official - Phone:191-738-3575
Mailing Address - Street 1:2150 E TREMONT AVE APT 5G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-5732
Mailing Address - Country:US
Mailing Address - Phone:917-383-5753
Mailing Address - Fax:
Practice Address - Street 1:2150 E TREMONT AVE APT 5G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-5732
Practice Address - Country:US
Practice Address - Phone:917-383-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18102958-01OtherFEE FOR SERVICE
NY18102958-01Medicaid
NM18102958-01Other18102958-01