Healthcare Provider Details

I. General information

NPI: 1770032534
Provider Name (Legal Business Name): LIFESKILLS DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 SHEPHERD DR
SAN BERNARDINO CA
92407-2251
US

IV. Provider business mailing address

6095 SHEPHERD DR
SAN BERNARDINO CA
92407-2251
US

V. Phone/Fax

Practice location:
  • Phone: 917-981-0503
  • Fax:
Mailing address:
  • Phone: 917-981-0503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. RAYMOND ARTHUR BESSE
Title or Position: DEPUTY DIRECTOR
Credential: QMHA, M.DIV, PSYD
Phone: 917-981-0503