Provider Demographics
NPI:1003660036
Name:LIFESOURCE THERAPY LLC
Entity Type:Organization
Organization Name:LIFESOURCE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:541-777-7230
Mailing Address - Street 1:1900 NE 3RD ST STE 106
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3889
Mailing Address - Country:US
Mailing Address - Phone:541-777-7230
Mailing Address - Fax:
Practice Address - Street 1:8180 SW CRATER LOOP RD
Practice Address - Street 2:
Practice Address - City:TERREBONNE
Practice Address - State:OR
Practice Address - Zip Code:97760-9004
Practice Address - Country:US
Practice Address - Phone:541-777-7230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)