Provider Demographics
NPI:1790180743
Name:LIFESPAN WELLNESS LLC
Entity Type:Organization
Organization Name:LIFESPAN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON-JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-386-0063
Mailing Address - Street 1:8200 MOUNTAIN RD NE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7835
Mailing Address - Country:US
Mailing Address - Phone:505-385-0161
Mailing Address - Fax:505-544-4648
Practice Address - Street 1:8200 MOUNTAIN RD NE STE 101
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7835
Practice Address - Country:US
Practice Address - Phone:505-385-0161
Practice Address - Fax:505-544-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4880277251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health