Provider Demographics
NPI:1538679832
Name:LIFELONG BEHAVIORAL SERVICES, LLC
Entity Type:Organization
Organization Name:LIFELONG BEHAVIORAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:LOEWEN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:850-626-6132
Mailing Address - Street 1:4629 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-4107
Mailing Address - Country:US
Mailing Address - Phone:850-503-6636
Mailing Address - Fax:850-626-6132
Practice Address - Street 1:4629 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-4107
Practice Address - Country:US
Practice Address - Phone:850-503-6636
Practice Address - Fax:850-626-6132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFELONG BEHAVIORAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-02
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-13522103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty