Provider Demographics
NPI:1306104732
Name:LIFE DESIGNS
Entity type:Organization
Organization Name:LIFE DESIGNS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:210-632-4147
Mailing Address - Street 1:400 N LOOP 1604 E
Mailing Address - Street 2:SUITE 175
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1258
Mailing Address - Country:US
Mailing Address - Phone:210-632-4147
Mailing Address - Fax:210-545-4495
Practice Address - Street 1:400 N LOOP 1604 E
Practice Address - Street 2:SUITE 175
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1258
Practice Address - Country:US
Practice Address - Phone:210-632-4147
Practice Address - Fax:210-545-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121917208Medicaid
TX11864139OtherCAQH
TX121917208OtherTPI NUMBER