Provider Demographics
NPI:1245254788
Name:LIFE ADVENTURE THERAPIES, LLC
Entity type:Organization
Organization Name:LIFE ADVENTURE THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER-PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUMMERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:262-241-9881
Mailing Address - Street 1:224 BUTTERNUT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4910
Mailing Address - Country:US
Mailing Address - Phone:262-241-9881
Mailing Address - Fax:262-365-0651
Practice Address - Street 1:11501 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE G-30
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3465
Practice Address - Country:US
Practice Address - Phone:262-241-9881
Practice Address - Fax:262-365-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI761-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty