Provider Demographics
NPI:1528688678
Name:LIFE EXTENSIONS LLC
Entity type:Organization
Organization Name:LIFE EXTENSIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW LCAS CSI SAP
Authorized Official - Phone:919-532-9855
Mailing Address - Street 1:1003 DRESSER CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7323
Mailing Address - Country:US
Mailing Address - Phone:919-532-9855
Mailing Address - Fax:919-803-7231
Practice Address - Street 1:2820 CALLIOPE WAY APT 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-6060
Practice Address - Country:US
Practice Address - Phone:919-532-9855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-19
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1790042356Medicaid
NC152868867Medicaid