Provider Demographics
NPI:1871852970
Name:HOME OF LIFE JOURNEY
Entity Type:Organization
Organization Name:HOME OF LIFE JOURNEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:817-769-0379
Mailing Address - Street 1:4228 HARDEMAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-3870
Mailing Address - Country:US
Mailing Address - Phone:817-769-0379
Mailing Address - Fax:
Practice Address - Street 1:4228 HARDEMAN ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-3870
Practice Address - Country:US
Practice Address - Phone:817-769-0379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty