Healthcare Provider Details

I. General information

NPI: 1457149056
Provider Name (Legal Business Name): LYFESUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CENTURY PARK S STE 106
BIRMINGHAM AL
35226-3925
US

IV. Provider business mailing address

400 CENTURY PARK S STE 106
BIRMINGHAM AL
35226-3925
US

V. Phone/Fax

Practice location:
  • Phone: 205-858-1656
  • Fax:
Mailing address:
  • Phone: 205-858-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JESSICA DAVIS
Title or Position: CHIEF OPERATING OFFICER
Credential: LICSW
Phone: 205-858-1656