Provider Demographics
NPI:1275079683
Name:LIFESPAN BEHAVIORAL HEALTH PLLC
Entity Type:Organization
Organization Name:LIFESPAN BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PERSOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-233-6576
Mailing Address - Street 1:1686 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-9403
Mailing Address - Country:US
Mailing Address - Phone:231-233-6576
Mailing Address - Fax:231-845-7095
Practice Address - Street 1:1686 N LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-9403
Practice Address - Country:US
Practice Address - Phone:231-233-6576
Practice Address - Fax:231-845-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI640-101-3191101YP2500X
MI1-16-22081103K00000X
MI630-101-5191103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty