Provider Demographics
NPI:1831531789
Name:HEALTHY LIFE INTERVENTIONS LLC
Entity type:Organization
Organization Name:HEALTHY LIFE INTERVENTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWONE
Authorized Official - Middle Name:EVERETT
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:405-274-5031
Mailing Address - Street 1:4010 N LINCOLN BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5214
Mailing Address - Country:US
Mailing Address - Phone:405-274-5031
Mailing Address - Fax:405-310-1791
Practice Address - Street 1:4010 N LINCOLN BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5220
Practice Address - Country:US
Practice Address - Phone:405-274-5031
Practice Address - Fax:405-310-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-20
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200496140BMedicaid