Provider Demographics
NPI:1477195154
Name:THE LIFE SOURCE LLC
Entity Type:Organization
Organization Name:THE LIFE SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LATEASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:762-207-8218
Mailing Address - Street 1:3228 UNIVERSITY AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-7201
Mailing Address - Country:US
Mailing Address - Phone:762-207-8218
Mailing Address - Fax:706-400-6478
Practice Address - Street 1:3228 UNIVERSITY AVE STE 103
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-7201
Practice Address - Country:US
Practice Address - Phone:762-207-8218
Practice Address - Fax:706-400-6478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty