Provider Demographics
NPI:1841809878
Name:LIFESPAN PSYCHOTHERAPY
Entity type:Organization
Organization Name:LIFESPAN PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DROSDICK
Authorized Official - Suffix:
Authorized Official - Credentials:MA NCC, CSAC, ATR-BC
Authorized Official - Phone:262-361-4275
Mailing Address - Street 1:510 HARTBROOK DR STE 204B
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1440
Mailing Address - Country:US
Mailing Address - Phone:126-236-1427
Mailing Address - Fax:262-313-0038
Practice Address - Street 1:510 HARTBROOK DR STE 204B
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1440
Practice Address - Country:US
Practice Address - Phone:126-236-1427
Practice Address - Fax:262-313-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528364825Medicaid