Provider Demographics
NPI:1538551072
Name:KING OF HEARTS LIFE ENHANCEMENT SERVICES, LLC
Entity type:Organization
Organization Name:KING OF HEARTS LIFE ENHANCEMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCADC
Authorized Official - Phone:732-240-2545
Mailing Address - Street 1:522 BRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6089
Mailing Address - Country:US
Mailing Address - Phone:732-240-2545
Mailing Address - Fax:732-475-6265
Practice Address - Street 1:522 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6089
Practice Address - Country:US
Practice Address - Phone:732-240-2545
Practice Address - Fax:732-475-6265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00161400101YP2500X
NJ37LC00034800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty