Provider Demographics
NPI:1659940377
Name:LIFESPAN PSYCHIATRIC SERVICES, LLC
Entity Type:Organization
Organization Name:LIFESPAN PSYCHIATRIC SERVICES, LLC
Other - Org Name:LIFESPAN PSYCHIATRIC & INTERNAL MEDICINE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP
Authorized Official - Phone:850-566-9190
Mailing Address - Street 1:1618 MAHAN CENTER BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5476
Mailing Address - Country:US
Mailing Address - Phone:850-999-2996
Mailing Address - Fax:
Practice Address - Street 1:1618 MAHAN CENTER BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5476
Practice Address - Country:US
Practice Address - Phone:850-999-2996
Practice Address - Fax:850-536-6439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-18
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty