Provider Demographics
NPI:1912958356
Name:LIFE SPAN PSYCHOLOGICAL SERVICES PC
Entity type:Organization
Organization Name:LIFE SPAN PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:G
Authorized Official - Last Name:RUCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:717-464-1464
Mailing Address - Street 1:28190 WILLOW ST PK
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584
Mailing Address - Country:US
Mailing Address - Phone:717-464-1464
Mailing Address - Fax:717-464-4348
Practice Address - Street 1:28190 WILLOW ST PK
Practice Address - Street 2:
Practice Address - City:WILLOW STREET
Practice Address - State:PA
Practice Address - Zip Code:17584
Practice Address - Country:US
Practice Address - Phone:717-464-1464
Practice Address - Fax:717-464-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW011339L104100000X
PASW123210L1041C0700X
PAPC002382101YP2500X
PAPS006874L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty