Provider Demographics
NPI:1235533506
Name:LIFE BRIDGE THERAPY
Entity Type:Organization
Organization Name:LIFE BRIDGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-329-1346
Mailing Address - Street 1:2507 CURTIS RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9630
Mailing Address - Country:US
Mailing Address - Phone:217-329-1346
Mailing Address - Fax:
Practice Address - Street 1:2507 CURTIS RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-9630
Practice Address - Country:US
Practice Address - Phone:217-329-1346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490153011041C0700X
IL166000861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty