Provider Demographics
NPI:1770047359
Name:LIFEGROWTH MARRIAGE AND FAMILY CENTER
Entity Type:Organization
Organization Name:LIFEGROWTH MARRIAGE AND FAMILY CENTER
Other - Org Name:LIFEGROWTH MARRIAGE AND FAMILY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GIANNINA
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:484-400-0445
Mailing Address - Street 1:1750 HAMPDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19604-1604
Mailing Address - Country:US
Mailing Address - Phone:484-400-0445
Mailing Address - Fax:
Practice Address - Street 1:5 S CENTRE AVE
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8653
Practice Address - Country:US
Practice Address - Phone:484-400-0445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty