Provider Demographics
NPI:1073212064
Name:LIFESTYLE ENHANCEMENT PARTNERS LLC
Entity Type:Organization
Organization Name:LIFESTYLE ENHANCEMENT PARTNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KURTASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:QMHPP
Authorized Official - Phone:276-806-9615
Mailing Address - Street 1:51 SHUMATE DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-1652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 SHUMATE DR
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078-1652
Practice Address - Country:US
Practice Address - Phone:276-806-9615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health