=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740002369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORE LYFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2024
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 CHADWICK DR
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-4622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-501-7151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 CHADWICK DR
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-4622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-501-7151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. HANNAH KAREN ENGLAND
-----------------------------------------------------
Credential | MASTERS
-----------------------------------------------------
Telephone | 520-709-9163
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------