Provider Demographics
NPI:1235412099
Name:LIFESIGHT THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:LIFESIGHT THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAINER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:770-815-4590
Mailing Address - Street 1:1690 WINDSONG PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-3262
Mailing Address - Country:US
Mailing Address - Phone:770-815-4590
Mailing Address - Fax:
Practice Address - Street 1:1690 WINDSONG PARK DR
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1169
Practice Address - Country:US
Practice Address - Phone:770-815-4590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I677320Medicare PIN