Provider Demographics
NPI:1316222037
Name:LIFE BY DESIGN
Entity type:Organization
Organization Name:LIFE BY DESIGN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LADC, CCS
Authorized Official - Phone:207-764-6825
Mailing Address - Street 1:147 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-3101
Mailing Address - Country:US
Mailing Address - Phone:207-764-8095
Mailing Address - Fax:
Practice Address - Street 1:7 HATCH DR
Practice Address - Street 2:290
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-2159
Practice Address - Country:US
Practice Address - Phone:207-492-1653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5029302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization