Provider Demographics
NPI:1710498829
Name:URBAN LIFE COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:URBAN LIFE COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-677-7053
Mailing Address - Street 1:220 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-1401
Mailing Address - Country:US
Mailing Address - Phone:973-677-7053
Mailing Address - Fax:973-677-7050
Practice Address - Street 1:220 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1401
Practice Address - Country:US
Practice Address - Phone:973-677-7053
Practice Address - Fax:973-677-7050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000623324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0314111Medicaid
NJ0314129Medicaid