Provider Demographics
NPI:1417209917
Name:LIFE RESTORATION CENTER
Entity Type:Organization
Organization Name:LIFE RESTORATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GRAHAM-DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:636-358-6021
Mailing Address - Street 1:124 WILD TURKEY LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-4339
Mailing Address - Country:US
Mailing Address - Phone:636-358-6021
Mailing Address - Fax:636-338-4911
Practice Address - Street 1:124 WILD TURKEY LN
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-4339
Practice Address - Country:US
Practice Address - Phone:636-358-6021
Practice Address - Fax:636-338-4911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007035322101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1538337159Medicaid