Provider Demographics
NPI:1366040396
Name:LIFEOLOGIE SAN DIEGO
Entity Type:Organization
Organization Name:LIFEOLOGIE SAN DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:HAYES
Authorized Official - Last Name:MOSESS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:619-493-0541
Mailing Address - Street 1:3188 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-1429
Mailing Address - Country:US
Mailing Address - Phone:323-229-2185
Mailing Address - Fax:
Practice Address - Street 1:3295 MEADE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-4557
Practice Address - Country:US
Practice Address - Phone:619-493-0541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGAPE COMMUNITY DEVELOPMENT CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty