Provider Demographics
NPI:1114225810
Name:LIFE THERAPY SPECIALISTS OF MD, LLC
Entity Type:Organization
Organization Name:LIFE THERAPY SPECIALISTS OF MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASTRACCO
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-417-4243
Mailing Address - Street 1:1927A YORK RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4225
Mailing Address - Country:US
Mailing Address - Phone:443-417-4243
Mailing Address - Fax:315-245-0352
Practice Address - Street 1:1927A YORK RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4225
Practice Address - Country:US
Practice Address - Phone:443-417-4243
Practice Address - Fax:315-245-0352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2273101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD922801200Medicaid