MEDICARE: A SALTED LYFE

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1700453263
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A SALTED LYFE

Provider Business Mailing Address
First Line	:	302 N EL CAMINO REAL STE 202
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4778
Country	:	US
Telephone Number	:	949-682-5521
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 N EL CAMINO REAL STE 202
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92672-4778
Country	:	US
Telephone Number	:	949-682-5521
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LYSSA KERRIGAN
Credential	:	LPCC
Telephone Number	:	949-682-5521

Provider Enumeration Date	:	06/04/2021
Last Update Date	:	06/04/2021

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Directions to “A SALTED LYFE ” Practice Location

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