Provider Demographics
NPI:1629485792
Name:SPHINX LIFE COACHING
Entity Type:Organization
Organization Name:SPHINX LIFE COACHING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-485-7941
Mailing Address - Street 1:276 BRANCH BROOK DR APT A
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3620
Mailing Address - Country:US
Mailing Address - Phone:862-485-7941
Mailing Address - Fax:
Practice Address - Street 1:276 BRANCH BROOK DR APT A
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3620
Practice Address - Country:US
Practice Address - Phone:862-485-7941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL055827001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0162353Medicaid