Healthcare Provider Details

I. General information

NPI: 1225047459
Provider Name (Legal Business Name): LIFESPAN THERAPY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 CAMINO DEL MONTE REY STE A2
SANTA FE NM
87505-3961
US

IV. Provider business mailing address

826 CAMINO DEL MONTE REY STE A2
SANTA FE NM
87505-3961
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-9940
  • Fax: 505-954-9946
Mailing address:
  • Phone: 505-954-9940
  • Fax: 505-954-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1011
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2423
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1562
License Number StateNM

VIII. Authorized Official

Name: MS. DANUSIA KIDANE
Title or Position: DIRECTOR
Credential: OTR/L
Phone: 505-954-9940