Provider Demographics
NPI:1780217653
Name:LIFESPAN PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:LIFESPAN PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSE PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLONI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:469-664-0070
Mailing Address - Street 1:8668 JOHN HICKMAN PKWY STE 1001
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9388
Mailing Address - Country:US
Mailing Address - Phone:469-664-0070
Mailing Address - Fax:469-217-3872
Practice Address - Street 1:8668 JOHN HICKMAN PKWY STE 804
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9386
Practice Address - Country:US
Practice Address - Phone:469-664-0070
Practice Address - Fax:469-217-3872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX411534701Medicaid