Provider Demographics
NPI:1457386831
Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC.
Entity Type:Organization
Organization Name:LIFE MANAGEMENT CENTER OF NORTHWEST FLORIDA INC.
Other - Org Name:LIFE MANAGEMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-522-4485
Mailing Address - Street 1:525 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5412
Mailing Address - Country:US
Mailing Address - Phone:850-522-4480
Mailing Address - Fax:850-914-6281
Practice Address - Street 1:2936 ORMOND AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-6986
Practice Address - Country:US
Practice Address - Phone:850-522-4480
Practice Address - Fax:850-914-6281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060296504Medicaid