Healthcare Provider Details

I. General information

NPI: 1457879520
Provider Name (Legal Business Name): LIFEBACK OF PENNSYLVANIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 12/28/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S CLINTON ST STE 100
DOYLESTOWN PA
18901-4220
US

IV. Provider business mailing address

10 S CLINTON ST STE 100
DOYLESTOWN PA
18901-4220
US

V. Phone/Fax

Practice location:
  • Phone: 609-482-3701
  • Fax: 215-975-7300
Mailing address:
  • Phone: 609-482-3701
  • Fax: 215-975-7300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARINETTA SEROTTE
Title or Position: PRESIDENT
Credential:
Phone: 609-482-3701