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General NPI Number Information
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NPI Number | 1376974378
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Entity Type | Organization
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Legal Business Name | LIFE STAGES THERAPY CENTER, INC
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 12/02/2013
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Provider Practice Location Address
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Address Line | 409 E COOK RD SUITE 100
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City | FORT WAYNE
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State | IN
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Zip | 46825-3600
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Country | US
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Telephone | 260-498-9933
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Fax |
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Provider Business Mailing Address
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Address Line | 2599 COUNTY ROAD 72
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City | AUBURN
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State | IN
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Zip | 46706-9624
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Country | US
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Telephone | 260-498-9933
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/COO
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Name | DR. MARLA JEAN SOUDER
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Credential | PSYD, HSPP
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Telephone | 260-498-9933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20042225A
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License Number State | IN
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