Provider Demographics
NPI:1982135265
Name:LIFE TREE PLLC
Entity type:Organization
Organization Name:LIFE TREE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOTON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C, PMHNP-BC
Authorized Official - Phone:805-504-6665
Mailing Address - Street 1:251 W STATE ROAD 198 STE 3
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5608
Mailing Address - Country:US
Mailing Address - Phone:801-504-6665
Mailing Address - Fax:801-504-6073
Practice Address - Street 1:251 W STATE ROAD 198 STE 3
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5608
Practice Address - Country:US
Practice Address - Phone:801-504-6665
Practice Address - Fax:801-504-9073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-27
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X, 261QM1300X, 363LA2200X, 363LF0000X, 363LG0600X, 363LP0808X
UT6227164-4405261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2019033956OtherANCC PMHNP BOARD CERTIFICATION