Provider Demographics
NPI:1104287564
Name:LIFESPAN COUNSELING CENTER LLC
Entity type:Organization
Organization Name:LIFESPAN COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:SYWULAK
Authorized Official - Last Name:MANNINO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-355-8812
Mailing Address - Street 1:729 GROVE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-6008
Mailing Address - Country:US
Mailing Address - Phone:215-355-8812
Mailing Address - Fax:215-355-0926
Practice Address - Street 1:729 GROVE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-6008
Practice Address - Country:US
Practice Address - Phone:215-355-8812
Practice Address - Fax:215-355-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA-003501-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty