Healthcare Provider Details

I. General information

NPI: 1184191553
Provider Name (Legal Business Name): LIFESPAN AUTISM AND BEHAVIORAL CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 GERI LN STE B
RICHMOND KY
40475-2691
US

IV. Provider business mailing address

PO BOX 1630
RICHMOND KY
40476-1630
US

V. Phone/Fax

Practice location:
  • Phone: 606-416-9220
  • Fax:
Mailing address:
  • Phone: 606-416-9220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: SUZETTE MORRISON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 606-416-9229