Healthcare Provider Details

I. General information

NPI: 1881486850
Provider Name (Legal Business Name): LIVECONSCIOUS THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 N ST STE N
SACRAMENTO CA
95816-5712
US

IV. Provider business mailing address

2108 N ST STE N
SACRAMENTO CA
95816-5712
US

V. Phone/Fax

Practice location:
  • Phone: 858-225-0888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: SU BOUDREAU
Title or Position: PRESIDENT
Credential:
Phone: 858-225-0888