Healthcare Provider Details

I. General information

NPI: 1992286306
Provider Name (Legal Business Name): LIFELAB KIDS FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 03/20/2024
Certification Date: 01/12/2024
Deactivation Date: 01/18/2024
Reactivation Date: 03/19/2024

III. Provider practice location address

3178 HILTON RD
FERNDALE MI
48220-1059
US

IV. Provider business mailing address

3178 HILTON RD
FERNDALE MI
48220-1059
US

V. Phone/Fax

Practice location:
  • Phone: 248-629-4600
  • Fax: 248-331-2744
Mailing address:
  • Phone: 248-629-4600
  • Fax: 248-331-2744

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 Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JAI REDDY DEPA
Title or Position: OWNER
Credential:
Phone: 248-629-4600