Basic Information
| Provider Information | |||||||||
| NPI: | 1528564358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LIFE BEHAVIORAL AND YOUTH DEVELOPMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 MORRIS AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712022067 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 MORRIS AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712022067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188165514 | ||||||||
| FaxNumber: | 3188165514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2018 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | ELEAM | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3186003962 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | LA | N | Agencies | Community/Behavioral Health | 251S00000X | BH0012306 | LA | N | Agencies | Community/Behavioral Health | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.