Provider Demographics
NPI:1679017966
Name:LIFEWALK
Entity Type:Organization
Organization Name:LIFEWALK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:941-875-4338
Mailing Address - Street 1:19 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-4341
Mailing Address - Country:US
Mailing Address - Phone:941-875-4338
Mailing Address - Fax:
Practice Address - Street 1:19 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-4341
Practice Address - Country:US
Practice Address - Phone:941-875-4338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1068101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1068OtherLCMHC NUMBER
FL12533OtherLMHC NUMBER
12727367OtherCAQH
1003230269OtherNPI INDIVIDUAL NUMBER
NH3098584Medicaid