Provider Demographics
NPI:1578955951
Name:BRONX LEBANON HOSPITAL LIFE RECOVERY CENTER
Entity Type:Organization
Organization Name:BRONX LEBANON HOSPITAL LIFE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-518-3736
Mailing Address - Street 1:28 DIXON ST
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-3304
Mailing Address - Country:US
Mailing Address - Phone:914-414-2829
Mailing Address - Fax:
Practice Address - Street 1:1285 FULTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3401
Practice Address - Country:US
Practice Address - Phone:718-518-3711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0738591261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)