Provider Demographics
NPI:1003438425
Name:LIFECARE WELLNESS PSYCHIATRIC GROUP
Entity Type:Organization
Organization Name:LIFECARE WELLNESS PSYCHIATRIC GROUP
Other - Org Name:LIFECARE WELLNESS PSYCHIATRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-391-7534
Mailing Address - Street 1:216 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:GORDO
Mailing Address - State:AL
Mailing Address - Zip Code:35466-2221
Mailing Address - Country:US
Mailing Address - Phone:205-391-7534
Mailing Address - Fax:205-344-9031
Practice Address - Street 1:653 HELEN KELLER BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-2983
Practice Address - Country:US
Practice Address - Phone:205-258-2249
Practice Address - Fax:205-293-5516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-07
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019045211OtherANCC