Provider Demographics
NPI:1003205741
Name:LIFESPAN PSYCHOLOGY, P.C.
Entity Type:Organization
Organization Name:LIFESPAN PSYCHOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WEIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:954-260-0361
Mailing Address - Street 1:98 VOORHEES RD E
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:GA
Mailing Address - Zip Code:31811-5671
Mailing Address - Country:US
Mailing Address - Phone:706-582-3647
Mailing Address - Fax:
Practice Address - Street 1:98 VOORHEES RD E
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:GA
Practice Address - Zip Code:31811-5671
Practice Address - Country:US
Practice Address - Phone:954-260-0361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-19
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003141103G00000X
GAPSY003142103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA712348695AMedicaid
GA313423941AMedicaid
GA313423941AMedicaid
GA511I260052Medicare PIN