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NPI Code Detail

MEDICARE: LIFE BALANCE THERAPY, LLC

MEDICARE: LIFE BALANCE THERAPY, 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
1251S00000XCommunity/Behavioral Health Agency0000002511TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12511OTHERTNINSTAMED

General Provider Information

NPI Number : 1902174949
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIFE BALANCE THERAPY, LLC
Provider Business Mailing Address
First Line : 313 LOONEY AVE
Second Line :
City : MEMPHIS
State : TN
Zip : 38107-3790
Country : US
Telephone Number : 901-598-2431
Fax Number :
Provider Business Practice Location Address
First Line : 5865 RIDGEWAY CENTER PKWY STE 300
Second Line :
City : MEMPHIS
State : TN
Zip : 38120-4014
Country : US
Telephone Number : 901-598-2431
Fax Number :
Authorized Official
Title or Position : OWNER/PSYCHOTHERAPY
Name : EBONY BAILEY
Credential : MA, LPC-MHSP
Telephone Number : 901-598-2431
Provider Enumeration Date : 12/06/2011
Last Update Date : 04/08/2022

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