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General NPI Number Information
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NPI Number | 1649578980
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Entity Type | Organization
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Legal Business Name | LIFE STAGE THERAPY
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Dates
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Enumeration Date | 03/10/2011
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Last Update Date | 03/10/2011
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Provider Practice Location Address
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Address Line | 3301 COORS BLVD NW STE R SUITE 148
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City | ALBUQUERQUE
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State | NM
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Zip | 87120-1268
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Country | US
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Telephone | 505-710-4259
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Fax |
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Provider Business Mailing Address
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Address Line | 3301 COORS BLVD NW STE R SUITE 148
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City | ALBUQUERQUE
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State | NM
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Zip | 87120-1268
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Country | US
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Telephone | 505-710-4259
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MICHAEL P MORSE
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Credential | LMFT
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Telephone | 505-710-4259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0248
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License Number State | NM
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