Provider Demographics
NPI:1144560574
Name:LIFE BRANCH INC.
Entity type:Organization
Organization Name:LIFE BRANCH INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:361-332-6551
Mailing Address - Street 1:5437 KING ACRES DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-6301
Mailing Address - Country:US
Mailing Address - Phone:361-332-6551
Mailing Address - Fax:361-687-2563
Practice Address - Street 1:5262 SOUTH STAPLES
Practice Address - Street 2:SUITE 300
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4116
Practice Address - Country:US
Practice Address - Phone:361-332-6551
Practice Address - Fax:361-687-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty