Provider Demographics
NPI:1255226916
Name:AYA LIFE THERAPY PLLC
Entity type:Organization
Organization Name:AYA LIFE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATREASA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:269-767-2980
Mailing Address - Street 1:1280 IROQUOIS AVE STE 102A
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8559
Mailing Address - Country:US
Mailing Address - Phone:331-230-0338
Mailing Address - Fax:
Practice Address - Street 1:1280 IROQUOIS AVE STE 102A
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8559
Practice Address - Country:US
Practice Address - Phone:331-230-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty