Provider Demographics
NPI:1396217816
Name:LIFESPARK PLLC
Entity Type:Organization
Organization Name:LIFESPARK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-702-8240
Mailing Address - Street 1:106 PUBLIC SQ STE 105
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3204
Mailing Address - Country:US
Mailing Address - Phone:615-675-0025
Mailing Address - Fax:615-675-0026
Practice Address - Street 1:106 PUBLIC SQ STE 105
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066
Practice Address - Country:US
Practice Address - Phone:615-675-0025
Practice Address - Fax:615-675-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-21
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Single Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1407328214OtherNPPES ORGANIZATIONAL NPI FOR MEANINGFUL LIVING LLC
1912478108OtherNPPES INDIVIDUAL NPI