Provider Demographics
NPI:1922888460
Name:LIFT UP LIVE WELL MENTAL HEALTHCARE
Entity Type:Organization
Organization Name:LIFT UP LIVE WELL MENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/APN
Authorized Official - Prefix:
Authorized Official - First Name:NRISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:212-918-4488
Mailing Address - Street 1:438 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-5741
Mailing Address - Country:US
Mailing Address - Phone:212-918-4488
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE RM 704
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4527
Practice Address - Country:US
Practice Address - Phone:212-918-4488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty