Provider Demographics
NPI:1730508441
Name:LIFEBRIDGE COMMUNITY PRACTICE
Entity type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GRAYSON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-296-5300
Mailing Address - Street 1:750 MAIN ST
Mailing Address - Street 2:STE. 202
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-2515
Mailing Address - Country:US
Mailing Address - Phone:410-526-3048
Mailing Address - Fax:410-526-3062
Practice Address - Street 1:750 MAIN ST
Practice Address - Street 2:STE. 202
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-2515
Practice Address - Country:US
Practice Address - Phone:410-526-3048
Practice Address - Fax:410-526-3062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty