Provider Demographics
NPI:1922789296
Name:LIFE JOURNEY GROUP, LLC
Entity Type:Organization
Organization Name:LIFE JOURNEY GROUP, LLC
Other - Org Name:LIFE JOURNEY GROUP, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALRICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEMONTEGNAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-500-6031
Mailing Address - Street 1:901 E VAN BUREN AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4239
Mailing Address - Country:US
Mailing Address - Phone:210-500-6031
Mailing Address - Fax:
Practice Address - Street 1:901 E VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4239
Practice Address - Country:US
Practice Address - Phone:210-500-6031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty