Provider Demographics
NPI:1861925968
Name:LIFE TREK, LLC
Entity type:Organization
Organization Name:LIFE TREK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STATON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:501-617-5678
Mailing Address - Street 1:21 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-3714
Mailing Address - Country:US
Mailing Address - Phone:501-617-5678
Mailing Address - Fax:
Practice Address - Street 1:21 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3714
Practice Address - Country:US
Practice Address - Phone:501-617-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17-04P103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty