Healthcare Provider Details

I. General information

NPI: 1275437329
Provider Name (Legal Business Name): LIFE PHASES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4861 IMPERIAL DR
LIBERTY TWP OH
45011-9089
US

IV. Provider business mailing address

4861 IMPERIAL DR
LIBERTY TWP OH
45011-9089
US

V. Phone/Fax

Practice location:
  • Phone: 513-405-7862
  • Fax:
Mailing address:
  • Phone: 513-405-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: TANISHA PERINE-DIXON
Title or Position: CLINICAL COUNSELOR
Credential: LPCC-S
Phone: 513-405-7862