Provider Demographics
NPI:1063155422
Name:LIFEOLOGIST WELLNESS & EDUCATIONAL CONSULTANT
Entity type:Organization
Organization Name:LIFEOLOGIST WELLNESS & EDUCATIONAL CONSULTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:EASAW-FAVOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-378-5009
Mailing Address - Street 1:PO BOX 58450
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99711-0450
Mailing Address - Country:US
Mailing Address - Phone:907-378-5009
Mailing Address - Fax:
Practice Address - Street 1:815 2ND AVE STE 112
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4469
Practice Address - Country:US
Practice Address - Phone:907-378-5009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty