Provider Demographics
NPI:1134698509
Name:LIFE MATRIX NC PLLC
Entity Type:Organization
Organization Name:LIFE MATRIX NC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-797-7354
Mailing Address - Street 1:100 HAY ST STE 701
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5487
Mailing Address - Country:US
Mailing Address - Phone:910-797-7354
Mailing Address - Fax:
Practice Address - Street 1:100 HAY ST STE 701
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5487
Practice Address - Country:US
Practice Address - Phone:910-444-1996
Practice Address - Fax:800-337-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty