Provider Demographics
NPI:1225047459
Name:LIFESPAN THERAPY SERVICES, INC.
Entity Type:Organization
Organization Name:LIFESPAN THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DANUSIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDANE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:505-954-9940
Mailing Address - Street 1:826 CAMINO DEL MONTE REY STE A2
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3961
Mailing Address - Country:US
Mailing Address - Phone:505-954-9940
Mailing Address - Fax:505-954-9946
Practice Address - Street 1:826 CAMINO DEL MONTE REY STE A2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3961
Practice Address - Country:US
Practice Address - Phone:505-954-9940
Practice Address - Fax:505-954-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1011225100000X
NM1562225X00000X
NM2423235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM202006808OtherPRESBYTERIAN PROVIDER
NMA1205OtherMEDICAID WAIVER PROVIDER