Provider Demographics
NPI:1043703242
Name:ELEVATED LIFE
Entity Type:Organization
Organization Name:ELEVATED LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ LMFT
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, PPS
Authorized Official - Phone:909-437-0765
Mailing Address - Street 1:PO BOX 1887
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-1887
Mailing Address - Country:US
Mailing Address - Phone:909-437-0765
Mailing Address - Fax:909-854-5880
Practice Address - Street 1:818 N MOUNTAIN AVE STE 219
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4165
Practice Address - Country:US
Practice Address - Phone:909-437-0765
Practice Address - Fax:909-854-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45458106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty