Healthcare Provider Details

I. General information

NPI: 1508317504
Provider Name (Legal Business Name): LIFE GROUP PSYCHOTHERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S AUSTRALIAN AVE SUITE 639
WEST PALM BEACH FL
33401-6223
US

IV. Provider business mailing address

500 S AUSTRALIAN AVE SUITE 639
WEST PALM BEACH FL
33401-6223
US

V. Phone/Fax

Practice location:
  • Phone: 561-236-0854
  • Fax: 419-851-9191
Mailing address:
  • Phone: 561-236-0854
  • Fax: 419-851-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DILLON STEINMAN
Title or Position: PRESIDENT
Credential:
Phone: 561-236-0854