Provider Demographics
NPI:1972381846
Name:LIFESTREAM THERAPY, LLC
Entity Type:Organization
Organization Name:LIFESTREAM THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GMINDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-448-7035
Mailing Address - Street 1:23520 MARBLEHEAD CIR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92587-7706
Mailing Address - Country:US
Mailing Address - Phone:951-448-7035
Mailing Address - Fax:
Practice Address - Street 1:10162 E OLLA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2378
Practice Address - Country:US
Practice Address - Phone:951-448-7035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty