Provider Demographics
NPI:1760731301
Name:LIFE TRANSITION SERVICE
Entity Type:Organization
Organization Name:LIFE TRANSITION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:586-663-8906
Mailing Address - Street 1:21031 SUNNYDALE
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR SHORE
Mailing Address - State:MI
Mailing Address - Zip Code:48081
Mailing Address - Country:US
Mailing Address - Phone:586-663-8906
Mailing Address - Fax:
Practice Address - Street 1:21031 SUNNYDALE
Practice Address - Street 2:
Practice Address - City:ST. CLAIR SHORE
Practice Address - State:MI
Practice Address - Zip Code:48081
Practice Address - Country:US
Practice Address - Phone:586-663-8906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47041996416251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health