Provider Demographics
NPI:1740659036
Name:BREAD OF LIFE COMMUNITY SERVICES INC.
Entity type:Organization
Organization Name:BREAD OF LIFE COMMUNITY SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-892-5022
Mailing Address - Street 1:1055 SHERMAN AVE APT 4B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-5720
Mailing Address - Country:US
Mailing Address - Phone:347-892-5022
Mailing Address - Fax:
Practice Address - Street 1:14 W 170TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-3227
Practice Address - Country:US
Practice Address - Phone:347-892-5022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082977251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health