Provider Demographics
NPI:1619313186
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/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:CBHCMS
Authorized Official - Phone:786-303-5079
Mailing Address - Street 1:2050 W 56TH ST
Mailing Address - Street 2:SUITE 15-16
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2601
Mailing Address - Country:US
Mailing Address - Phone:786-303-5079
Mailing Address - Fax:305-825-8117
Practice Address - Street 1:2050 W 56TH ST
Practice Address - Street 2:SUITE 15-16
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2601
Practice Address - Country:US
Practice Address - Phone:786-303-5079
Practice Address - Fax:305-825-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008666100Medicaid