Provider Demographics
NPI:1891865549
Name:NORTHEAST LIFE SKILLS ASSOCIATES INC
Entity Type:Organization
Organization Name:NORTHEAST LIFE SKILLS ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ILLGE
Authorized Official - Suffix:
Authorized Official - Credentials:MHS
Authorized Official - Phone:973-777-2962
Mailing Address - Street 1:121 HOWE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:973-777-2962
Mailing Address - Fax:973-777-7623
Practice Address - Street 1:121 HOWE AVENUE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-777-2962
Practice Address - Fax:973-777-7623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22306261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0101401Medicaid