Healthcare Provider Details

I. General information

NPI: 1649578980
Provider Name (Legal Business Name): LIFE STAGE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 COORS BLVD NW STE R SUITE 148
ALBUQUERQUE NM
87120-1268
US

IV. Provider business mailing address

3301 COORS BLVD NW STE R SUITE 148
ALBUQUERQUE NM
87120-1268
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-4259
  • Fax:
Mailing address:
  • Phone: 505-710-4259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0248
License Number StateNM

VIII. Authorized Official

Name: MR. MICHAEL P MORSE
Title or Position: OWNER
Credential: LMFT
Phone: 505-710-4259