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General NPI Number Information
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NPI Number | 1790180743
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Entity Type | Organization
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Legal Business Name | LIFESPAN WELLNESS LLC
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Dates
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Enumeration Date | 11/01/2014
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 8200 MOUNTAIN RD NE STE 101
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-7835
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Country | US
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Telephone | 505-385-0161
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Fax | 505-544-4648
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Provider Business Mailing Address
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Address Line | 8200 MOUNTAIN RD NE STE 101
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-7835
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Country | US
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Telephone | 505-385-0161
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Fax | 505-544-4648
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. ERIKA K JOHNSON-JIMENEZ
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Credential | PH.D.
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Telephone | 505-386-0063
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4880277
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License Number State | NM
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