Provider Demographics
NPI:1578182770
Name:LIFETIME CHANGES BEHAVIOR SERVICES LLC
Entity Type:Organization
Organization Name:LIFETIME CHANGES BEHAVIOR SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:929-256-0231
Mailing Address - Street 1:683 HENDERSON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1575
Mailing Address - Country:US
Mailing Address - Phone:929-256-0231
Mailing Address - Fax:
Practice Address - Street 1:683 HENDERSON AVE STE A
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1575
Practice Address - Country:US
Practice Address - Phone:929-256-0231
Practice Address - Fax:718-732-2628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health