Healthcare Provider Details

I. General information

NPI: 1619883956
Provider Name (Legal Business Name): TREE OF LIFE TOTAL WELLNESS IPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 PLANK RD STE 103
CLIFTON PARK NY
12065-4883
US

IV. Provider business mailing address

641 GROOMS RD # 186
CLIFTON PARK NY
12065-5912
US

V. Phone/Fax

Practice location:
  • Phone: 518-414-5706
  • Fax: 518-309-6213
Mailing address:
  • Phone: 518-414-5706
  • Fax: 518-309-6213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN CARSON
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 607-316-1583