Provider Demographics
NPI:1417739624
Name:IMPACT LIFE SOLUTIONS, LLC
Entity Type:Organization
Organization Name:IMPACT LIFE SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:DMIN
Authorized Official - Phone:248-571-4806
Mailing Address - Street 1:4204 BUCKINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3539
Mailing Address - Country:US
Mailing Address - Phone:248-571-4806
Mailing Address - Fax:
Practice Address - Street 1:4204 BUCKINGHAM AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-3539
Practice Address - Country:US
Practice Address - Phone:248-571-4806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-23
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty