Provider Demographics
NPI:1235608621
Name:LIFE EXPERIENCE
Entity Type:Organization
Organization Name:LIFE EXPERIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANIYAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-860-8899
Mailing Address - Street 1:2201 HARRY AND JUDY DR
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-1373
Mailing Address - Country:US
Mailing Address - Phone:973-860-8899
Mailing Address - Fax:
Practice Address - Street 1:2201 HARRY AND JUDY DR
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-1373
Practice Address - Country:US
Practice Address - Phone:973-860-8899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========Medicaid