Healthcare Provider Details

I. General information

NPI: 1487121687
Provider Name (Legal Business Name): LIFESPRING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 EVERSMAN DR
JASPER IN
47546-3548
US

IV. Provider business mailing address

480 EVERSMAN DR
JASPER IN
47546-3548
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-3020
  • Fax:
Mailing address:
  • Phone: 812-482-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRY STAWAR
Title or Position: CEO
Credential:
Phone: 812-206-1234