Provider Demographics
NPI:1477071637
Name:NEW LIFE BEHAVIORAL HEALTH PROGRAM LLC
Entity Type:Organization
Organization Name:NEW LIFE BEHAVIORAL HEALTH PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:L
Authorized Official - Last Name:STATEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-270-4357
Mailing Address - Street 1:3627 KEYSTONE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5616
Mailing Address - Country:US
Mailing Address - Phone:323-309-1645
Mailing Address - Fax:
Practice Address - Street 1:1818 WALBROOK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1311
Practice Address - Country:US
Practice Address - Phone:443-270-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty