Provider Demographics
NPI:1033770904
Name:LIFE RE-CREATED LLC
Entity Type:Organization
Organization Name:LIFE RE-CREATED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHRYN
Authorized Official - Middle Name:ANA
Authorized Official - Last Name:GLENDAY
Authorized Official - Suffix:
Authorized Official - Credentials:MPH MA LPCC
Authorized Official - Phone:505-369-6756
Mailing Address - Street 1:PO BOX 8946
Mailing Address - Street 2:C/O CATHRYN GLENDAY
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87198-8946
Mailing Address - Country:US
Mailing Address - Phone:505-369-6756
Mailing Address - Fax:505-393-5201
Practice Address - Street 1:3939 SAN PEDRO DR. NE
Practice Address - Street 2:BLD C, STE 8
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-369-6756
Practice Address - Fax:505-393-5201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9673365Medicaid