Provider Demographics
NPI:1952590911
Name:LIFELINE YOUTH & FAMILY SERVICES, INC.
Entity Type:Organization
Organization Name:LIFELINE YOUTH & FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-745-3322
Mailing Address - Street 1:PO BOX 80487
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-0487
Mailing Address - Country:US
Mailing Address - Phone:260-745-3322
Mailing Address - Fax:
Practice Address - Street 1:27 PEQUIGNOT DRIVE
Practice Address - Street 2:
Practice Address - City:PIERCETON
Practice Address - State:IN
Practice Address - Zip Code:46562-9075
Practice Address - Country:US
Practice Address - Phone:260-745-3322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200847310Medicaid
IN200847300Medicaid