Provider Demographics
NPI:1376155051
Name:ULTIMATE LIFE TELETHERAPY PLLC
Entity Type:Organization
Organization Name:ULTIMATE LIFE TELETHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:248-563-7226
Mailing Address - Street 1:6842 CORRIGAN DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-8852
Mailing Address - Country:US
Mailing Address - Phone:248-563-7226
Mailing Address - Fax:248-569-9410
Practice Address - Street 1:6842 CORRIGAN DR
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-8852
Practice Address - Country:US
Practice Address - Phone:248-563-7226
Practice Address - Fax:248-569-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty