Provider Demographics
NPI:1396491403
Name:LIFESPAN PSYCHOLOGICAL HEALTH COOPERATIVE
Entity type:Organization
Organization Name:LIFESPAN PSYCHOLOGICAL HEALTH COOPERATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:262-223-3082
Mailing Address - Street 1:13035 W BLUEMOUND RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-8001
Mailing Address - Country:US
Mailing Address - Phone:262-784-1121
Mailing Address - Fax:
Practice Address - Street 1:13035 W BLUEMOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8001
Practice Address - Country:US
Practice Address - Phone:262-784-1121
Practice Address - Fax:262-784-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty