Provider Demographics
NPI:1700132933
Name:LIFECYCLE THERAPEUTIC SERVICES LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:LIFECYCLE THERAPEUTIC SERVICES LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-571-4062
Mailing Address - Street 1:349 FRANKLIN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-4004
Mailing Address - Country:US
Mailing Address - Phone:973-517-4062
Mailing Address - Fax:
Practice Address - Street 1:349 FRANKLIN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-4004
Practice Address - Country:US
Practice Address - Phone:973-517-4062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty