Provider Demographics
NPI:1598134983
Name:LIFE WATER SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:LIFE WATER SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:LATEASE
Authorized Official - Last Name:BISHOPJOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:734-444-8512
Mailing Address - Street 1:23999 W 10 MILE RD # 220
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3158
Mailing Address - Country:US
Mailing Address - Phone:248-327-6593
Mailing Address - Fax:248-996-8903
Practice Address - Street 1:23999 W 10 MILE RD # 220
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-3158
Practice Address - Country:US
Practice Address - Phone:248-327-6593
Practice Address - Fax:248-996-8903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 251B00000X
MI6401009531251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty