Provider Demographics
NPI:1225240633
Name:LEADING YOUTH THROUGH EXPERIENCE, LLC
Entity Type:Organization
Organization Name:LEADING YOUTH THROUGH EXPERIENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-458-3201
Mailing Address - Street 1:PO BOX D
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-0055
Mailing Address - Country:US
Mailing Address - Phone:732-458-3201
Mailing Address - Fax:
Practice Address - Street 1:448 19TH AVE
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724
Practice Address - Country:US
Practice Address - Phone:732-458-3201
Practice Address - Fax:732-458-3269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2007-08-16
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-16
Provider Licenses
StateLicense IDTaxonomies
NJ44SC04652800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0061913Medicaid