Healthcare Provider Details

I. General information

NPI: 1447885777
Provider Name (Legal Business Name): LIFESTAGES FAMILY NEUROHEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 S RIVER RD UNIT 33
BEDFORD NH
03110-6721
US

IV. Provider business mailing address

40 S RIVER RD UNIT 33
BEDFORD NH
03110-6721
US

V. Phone/Fax

Practice location:
  • Phone: 603-614-6016
  • Fax:
Mailing address:
  • Phone: 603-614-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JAMIE L TIMMINS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 603-233-9801