Provider Demographics
NPI:1780093294
Name:LIFESTAR SACRAMENTO
Entity type:Organization
Organization Name:LIFESTAR SACRAMENTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT,CSAT, CMAT
Authorized Official - Phone:916-728-5433
Mailing Address - Street 1:8261 GREENBACK LN STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2533
Mailing Address - Country:US
Mailing Address - Phone:916-728-5433
Mailing Address - Fax:
Practice Address - Street 1:8261 GREENBACK LN STE 100
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-2533
Practice Address - Country:US
Practice Address - Phone:916-728-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36717106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty