Provider Demographics
NPI:1326637778
Name:PSYCHED FOR LIFE LLC
Entity Type:Organization
Organization Name:PSYCHED FOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:360-582-7908
Mailing Address - Street 1:713 S ALDER LN
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-8462
Mailing Address - Country:US
Mailing Address - Phone:136-058-2790
Mailing Address - Fax:
Practice Address - Street 1:713 S ALDER LN
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-8462
Practice Address - Country:US
Practice Address - Phone:136-058-2790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health