Provider Demographics
NPI:1114673308
Name:LIFESPAN BEHAVIORAL HEALTH SERVICES PC
Entity Type:Organization
Organization Name:LIFESPAN BEHAVIORAL HEALTH SERVICES PC
Other - Org Name:LIFESPAN BEHAVIORAL HEALTH SERVICES PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSSAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-982-3437
Mailing Address - Street 1:3416 OLANDWOOD CT STE 201
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1373
Mailing Address - Country:US
Mailing Address - Phone:301-969-4060
Mailing Address - Fax:301-982-9452
Practice Address - Street 1:3460 OLNEY LAYTONSVILLE RD STE 212
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-3701
Practice Address - Country:US
Practice Address - Phone:301-982-3437
Practice Address - Fax:301-982-9452
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPAN BEHAVIORAL HEALTH SERVICES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-25
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)