MEDICARE: LIFE PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	6801035053	MI
2	251S00000X	Community/Behavioral Health Agency	6401006504	MI

General Provider Information

NPI Number	:	1669725875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE PRACTICE LLC

Provider Business Mailing Address
First Line	:	2006 S WAYNE RD
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48186-5428
Country	:	US
Telephone Number	:	313-799-0093
Fax Number	:	734-467-3965

Provider Business Practice Location Address
First Line	:	2006 S WAYNE RD
Second Line	:
City	:	WESTLAND
State	:	MI
Zip	:	48186-5428
Country	:	US
Telephone Number	:	313-799-0093
Fax Number	:	734-467-3965

Authorized Official
Title or Position	:	THERAPIST
Name	:	MS. BETTY ANN RICKMAN
Credential	:	LMSW,LPC
Telephone Number	:	313-799-0093

Provider Enumeration Date	:	10/25/2012
Last Update Date	:	10/25/2012

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Directions to “LIFE PRACTICE LLC ” Practice Location

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