Provider Demographics
NPI:1184876104
Name:RE-ENTRY LINK
Entity type:Organization
Organization Name:RE-ENTRY LINK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON-LACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-995-5465
Mailing Address - Street 1:1451 WEST AVE STE 1-11
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-7304
Mailing Address - Country:US
Mailing Address - Phone:347-997-5465
Mailing Address - Fax:877-333-8118
Practice Address - Street 1:1451 WEST AVE STE 1-11
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:347-997-5465
Practice Address - Fax:877-333-8118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251S00000X, 261QM0850X, 261QM0855X, 324500000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
12345678OtherNA