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General NPI Number Information
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NPI Number | 1255226916
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Entity Type | Organization
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Legal Business Name | AYA LIFE THERAPY PLLC
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Dates
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Enumeration Date | 06/11/2025
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Last Update Date | 06/11/2025
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Provider Practice Location Address
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Address Line | 1280 IROQUOIS AVE STE 102A
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City | NAPERVILLE
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State | IL
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Zip | 60563-8559
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Country | US
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Telephone | 331-230-0338
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Fax |
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Provider Business Mailing Address
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Address Line | 1280 IROQUOIS AVE STE 102A
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City | NAPERVILLE
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State | IL
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Zip | 60563-8559
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Country | US
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Telephone | 331-230-0338
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICAL THERAPIST
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Name | MRS. LATREASA DENISE BLACKMON
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Credential | LCPC
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Telephone | 269-767-2980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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