Healthcare Provider Details

I. General information

NPI: 1588404636
Provider Name (Legal Business Name): LIFE HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10565 LIFE HOUSE STREET
ST. JAMES LA
70086
US

IV. Provider business mailing address

10565 LIFE HOUSE STREET
ST. JAMES LA
70086
US

V. Phone/Fax

Practice location:
  • Phone: 225-644-3762
  • Fax:
Mailing address:
  • Phone: 225-644-3762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFERY ROBERT
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 225-268-7998