Provider Demographics
NPI:1316441223
Name:FAMILY LIFE FOUNDATION INCORPORATION
Entity type:Organization
Organization Name:FAMILY LIFE FOUNDATION INCORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OWOLABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-570-4860
Mailing Address - Street 1:11721 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3320
Mailing Address - Country:US
Mailing Address - Phone:443-405-3744
Mailing Address - Fax:443-405-3778
Practice Address - Street 1:11721 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3320
Practice Address - Country:US
Practice Address - Phone:443-405-3744
Practice Address - Fax:443-405-3778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY LIFE FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-23
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5766138000OtherNPI
MD766138000Medicaid