Provider Demographics
NPI:1366615205
Name:LIFE-SPAN PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:LIFE-SPAN PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:LEHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:262-784-1121
Mailing Address - Street 1:13035 W BLUEMOUND RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-8001
Mailing Address - Country:US
Mailing Address - Phone:262-784-1121
Mailing Address - Fax:414-425-5113
Practice Address - Street 1:13035 W BLUEMOUND RD STE 100
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8001
Practice Address - Country:US
Practice Address - Phone:262-784-1121
Practice Address - Fax:262-784-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3073-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43571100Medicaid