Healthcare Provider Details

I. General information

NPI: 1396491403
Provider Name (Legal Business Name): LIFESPAN PSYCHOLOGICAL HEALTH COOPERATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13035 W BLUEMOUND RD STE 100
BROOKFIELD WI
53005-8001
US

IV. Provider business mailing address

13035 W BLUEMOUND RD STE 100
BROOKFIELD WI
53005-8001
US

V. Phone/Fax

Practice location:
  • Phone: 262-784-1121
  • Fax: 262-784-9777
Mailing address:
  • Phone: 262-784-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: SARAH LARSON
Title or Position: OFFICE ADMINISTRATION
Credential: LMFT
Phone: 262-223-3082