Provider Demographics
NPI:1578233854
Name:LIFECONNECT
Entity Type:Organization
Organization Name:LIFECONNECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNHARD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CRC, CESP
Authorized Official - Phone:330-883-4626
Mailing Address - Street 1:153 DIAMOND WAY
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1906
Mailing Address - Country:US
Mailing Address - Phone:330-883-4626
Mailing Address - Fax:
Practice Address - Street 1:153 DIAMOND WAY
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-1906
Practice Address - Country:US
Practice Address - Phone:330-883-4626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services