Provider Demographics
NPI:1306297668
Name:LIFESPAN HOME WELLNESS, LLC
Entity type:Organization
Organization Name:LIFESPAN HOME WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MS, CCC-SLP
Authorized Official - Prefix:
Authorized Official - First Name:AISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDUL-SAMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-306-9406
Mailing Address - Street 1:5615 ASHBURN TER
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-9491
Mailing Address - Country:US
Mailing Address - Phone:443-306-9406
Mailing Address - Fax:
Practice Address - Street 1:5615 ASHBURN TER
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-9491
Practice Address - Country:US
Practice Address - Phone:555-555-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05356251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health