Provider Demographics
NPI:1962058545
Name:LIFE CYCLES THERAPY AND ENRICHMENT CENTER PLLC
Entity type:Organization
Organization Name:LIFE CYCLES THERAPY AND ENRICHMENT CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OTR-L
Authorized Official - Phone:313-854-1180
Mailing Address - Street 1:25999 FRANKLIN POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1567
Mailing Address - Country:US
Mailing Address - Phone:313-854-1189
Mailing Address - Fax:
Practice Address - Street 1:1200 MARTIN LUTHER KING JR BLVD # A
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2478
Practice Address - Country:US
Practice Address - Phone:313-854-1189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-10
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontologyGroup - Multi-Specialty
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Multi-Specialty
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitationGroup - Multi-Specialty