Provider Demographics
NPI:1215170857
Name:LIFESTREAM BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:LIFESTREAM BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSALYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MALMFTLSOT
Authorized Official - Phone:713-480-3534
Mailing Address - Street 1:515A S FRY RD # 306
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2214
Mailing Address - Country:US
Mailing Address - Phone:713-480-3534
Mailing Address - Fax:
Practice Address - Street 1:1270 COUNTY ROAD 2293
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-0299
Practice Address - Country:US
Practice Address - Phone:713-480-3534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-13
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX323P00000X
324500000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX028325101Medicaid