Basic Information
| Provider Information | |||||||||
| NPI: | 1205104635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFE SOLUTIONS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6249 E 21ST ST N | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162597766 | ||||||||
| FaxNumber: | 8774032982 | ||||||||
| Practice Location | |||||||||
| Address1: | 6249 E 21ST ST N | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162597766 | ||||||||
| FaxNumber: | 8774032982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORRIS | ||||||||
| AuthorizedOfficialFirstName: | STACIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3162597766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 899 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.