Healthcare Provider Details

I. General information

NPI: 1912958356
Provider Name (Legal Business Name): LIFE SPAN PSYCHOLOGICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28190 WILLOW ST PK
WILLOW STREET PA
17584
US

IV. Provider business mailing address

28190 WILLOW ST PK
WILLOW STREET PA
17584
US

V. Phone/Fax

Practice location:
  • Phone: 717-464-1464
  • Fax: 717-464-4348
Mailing address:
  • Phone: 717-464-1464
  • Fax: 717-464-4348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC002382
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS006874L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW011339L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW123210L
License Number StatePA

VIII. Authorized Official

Name: DR. LYNNETTE G RUCH
Title or Position: PHD
Credential: PHD
Phone: 717-464-1464