Provider Demographics
NPI:1932952835
Name:LIFEBLOOM MARRIAGE AND FAMILY THERAPY INC.
Entity Type:Organization
Organization Name:LIFEBLOOM MARRIAGE AND FAMILY THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBBRECHT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:209-505-1656
Mailing Address - Street 1:3405 VETERAN AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-5341
Mailing Address - Country:US
Mailing Address - Phone:209-505-1656
Mailing Address - Fax:
Practice Address - Street 1:3405 VETERAN AVE APT 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5341
Practice Address - Country:US
Practice Address - Phone:209-505-1656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty