Basic Information
| Provider Information | |||||||||
| NPI: | 1275079683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFESPAN BEHAVIORAL HEALTH PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1686 N LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494319403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312336576 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1686 N LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494319403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312336576 | ||||||||
| FaxNumber: | 2318457095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2017 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | PERSOON | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
| AuthorizedOfficialTelephone: | 2312336576 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 640-101-3191 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TB0200X | 630-101-5191 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103K00000X | 1-16-22081 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.