Provider Demographics
NPI:1922510890
Name:LIFE SOURCE LLC
Entity Type:Organization
Organization Name:LIFE SOURCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST--PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:HUSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC/CMHP
Authorized Official - Phone:406-360-5481
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-0127
Mailing Address - Country:US
Mailing Address - Phone:770-354-9621
Mailing Address - Fax:
Practice Address - Street 1:127 W MAIN ST STE B-2
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2581
Practice Address - Country:US
Practice Address - Phone:770-354-9621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT387-LCPC101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty