Provider Demographics
NPI:1063592608
Name:ESSENTIAL LIFE THERAPIES INC
Entity type:Organization
Organization Name:ESSENTIAL LIFE THERAPIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:540-989-0315
Mailing Address - Street 1:PO BOX 4127
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-0127
Mailing Address - Country:US
Mailing Address - Phone:540-981-9394
Mailing Address - Fax:540-344-7154
Practice Address - Street 1:5507 DOWNING ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8704
Practice Address - Country:US
Practice Address - Phone:540-989-0315
Practice Address - Fax:540-774-1292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008925721Medicaid
VA215418OtherANTHEM BCBS
VA008925721Medicaid