MEDICARE: LIFE BRIDGE THERAPY SERVICES 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1811510308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE BRIDGE THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	26151 LAKE SHORE BLVD APT 1409
Second Line	:
City	:	EUCLID
State	:	OH
Zip	:	44132-1156
Country	:	US
Telephone Number	:	216-533-2614
Fax Number	:

Provider Business Practice Location Address
First Line	:	5010 MAYFIELD RD STE 210
Second Line	:
City	:	LYNDHURST
State	:	OH
Zip	:	44124-2692
Country	:	US
Telephone Number	:	216-533-2614
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	KELVETTE BEACHAM
Credential	:
Telephone Number	:	216-533-2614

Provider Enumeration Date	:	05/19/2020
Last Update Date	:	07/25/2022

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