Basic Information
| Provider Information | |||||||||
| NPI: | 1003562299 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFESPAN BEHAVIORAL HEALTH SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 W 7TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012456300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1003 W 7TH ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217014106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012456300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2022 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | SUSSAL | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3019823437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFESPAN BEHAVIORAL HEALTH SERVICES PC | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.