Provider Demographics
NPI:1881001857
Name:DIVERSIFIED LIFESTYLE SERVICES
Entity Type:Organization
Organization Name:DIVERSIFIED LIFESTYLE SERVICES
Other - Org Name:DIVERSIFIED LIFESTYLE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANCASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-239-5563
Mailing Address - Street 1:14303 KENLON LN
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3745
Mailing Address - Country:US
Mailing Address - Phone:301-804-8279
Mailing Address - Fax:240-204-8153
Practice Address - Street 1:137 NATIONAL PLZ
Practice Address - Street 2:SUITE 300
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-1152
Practice Address - Country:US
Practice Address - Phone:301-804-8279
Practice Address - Fax:240-204-8153
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LANCASTER, FRAZIER, AND ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-22
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5764101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD755104500Medicaid