Healthcare Provider Details

I. General information

NPI: 1235533506
Provider Name (Legal Business Name): LIFE BRIDGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2507 CURTIS RD
CHAMPAIGN IL
61822-9630
US

IV. Provider business mailing address

2507 CURTIS RD
CHAMPAIGN IL
61822-9630
US

V. Phone/Fax

Practice location:
  • Phone: 217-329-1346
  • Fax:
Mailing address:
  • Phone: 217-329-1346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166000861
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149015301
License Number StateIL

VIII. Authorized Official

Name: DEBORAH CRANDALL
Title or Position: OWNER
Credential: LCSW
Phone: 217-329-1346