Provider Demographics
NPI:1568035269
Name:LIFESTAR MENTAL WELLNESS CENTER INC, CMHC
Entity Type:Organization
Organization Name:LIFESTAR MENTAL WELLNESS CENTER INC, CMHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-303-5079
Mailing Address - Street 1:1199 NE 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:FLORIDA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33034-2409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3414 W 84TH ST STE D110
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-4932
Practice Address - Country:US
Practice Address - Phone:786-303-5079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health