Provider Demographics
NPI:1861944977
Name:FUNCTIONAL LIFESTYLE SYSTEMS INC
Entity type:Organization
Organization Name:FUNCTIONAL LIFESTYLE SYSTEMS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERRIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-690-9592
Mailing Address - Street 1:1303 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6327
Mailing Address - Country:US
Mailing Address - Phone:970-690-9592
Mailing Address - Fax:970-353-7888
Practice Address - Street 1:503 REMINGTON ST STE 102
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3089
Practice Address - Country:US
Practice Address - Phone:970-690-9592
Practice Address - Fax:970-353-7888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2243103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60335378Medicaid