Provider Demographics
NPI:1194175497
Name:LIFE SUPPORT THERAPY SERVICES LLC
Entity type:Organization
Organization Name:LIFE SUPPORT THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LSW
Authorized Official - Phone:740-487-1768
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43702-2828
Mailing Address - Country:US
Mailing Address - Phone:740-487-1768
Mailing Address - Fax:740-870-0086
Practice Address - Street 1:4035 NORTHPOINTE DR UNIT B
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1738
Practice Address - Country:US
Practice Address - Phone:740-487-1768
Practice Address - Fax:740-870-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1194175497Medicaid