Provider Demographics
NPI:1952778243
Name:MENTAL HEALTH LIFESTYLE LLC
Entity Type:Organization
Organization Name:MENTAL HEALTH LIFESTYLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:440-574-1794
Mailing Address - Street 1:2181 BRIARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2833
Mailing Address - Country:US
Mailing Address - Phone:440-574-1794
Mailing Address - Fax:
Practice Address - Street 1:20525 CENTER RIDGE RD
Practice Address - Street 2:SUITE 303
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-3437
Practice Address - Country:US
Practice Address - Phone:440-574-1794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 1440201 SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty