Provider Demographics
NPI:1164909388
Name:SRQ LIFE THERAPY
Entity Type:Organization
Organization Name:SRQ LIFE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HABER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:941-685-7148
Mailing Address - Street 1:2477 STICKNEY POINT RD STE 115B
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-4092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2477 STICKNEY POINT RD STE 115B
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-4092
Practice Address - Country:US
Practice Address - Phone:941-685-7148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)