Basic Information
| Provider Information | |||||||||
| NPI: | 1295371896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE TRIBE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5940 SEABIRD DR S | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337073936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272012389 | ||||||||
| FaxNumber: | 8552244326 | ||||||||
| Practice Location | |||||||||
| Address1: | 2529 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272012389 | ||||||||
| FaxNumber: | 8552244326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2019 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7272012309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.