Organization
RE-ENTRY LINK
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER ELLISON-LACKARD (FOUNDER)
(347) 995-5465
Entity
Organization
Contact information
Practice address
1451 WEST AVE STE 1-11, BRONX, NY 10462
(347) 997-5465
(877) 333-8118
Mailing address
1451 WEST AVE STE 1-11, BRONX, NY 10462-7304
(347) 997-5465
(877) 333-8118
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
—
—
251S00000X
Community/Behavioral Health Agency
Primary
—
NC
251S00000X
Community/Behavioral Health Agency
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
324500000X
Substance Abuse Rehabilitation Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12345678
NA
—
Enumeration date
10/22/2008
Last updated
07/05/2018
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