Provider Demographics
NPI:1770844433
Name:LIFESPAN PSYCHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:LIFESPAN PSYCHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:BOOLUKOS
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:EDM, PSYD
Authorized Official - Phone:617-784-0771
Mailing Address - Street 1:4201 BAYSHORE BLVD
Mailing Address - Street 2:UNIT 1603
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1669
Mailing Address - Country:US
Mailing Address - Phone:617-784-0771
Mailing Address - Fax:
Practice Address - Street 1:4201 BAYSHORE BLVD
Practice Address - Street 2:UNIT 1603
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-1669
Practice Address - Country:US
Practice Address - Phone:617-784-0771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty