| Lifesource Therapy Llc | |
|
24455 Dodds Rd Bend OR 97701-9665 | |
| (541) 777-7230 | |
| Not Available |
| Full Name | Lifesource Therapy Llc |
|---|---|
| Speciality | Counselor |
| Location | 24455 Dodds Rd, Bend, Oregon |
| Authorized Official Name and Position | Gina R Lawrence (PROVIDER) |
| Authorized Official Contact | 5417777230 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lifesource Therapy Llc 1900 Ne 3rd St Ste 106 Bend OR 97701-3889 Ph: (541) 777-7230 | Lifesource Therapy Llc 24455 Dodds Rd Bend OR 97701-9665 Ph: (541) 777-7230 |
| NPI Number | 1003660036 |
|---|---|
| Provider Enumeration Date | 04/16/2024 |
| Last Update Date | 08/18/2025 |
| Certification Date | 08/18/2025 |
| Medicare PECOS PAC ID | 9133657752 |
|---|---|
| Medicare Enrollment ID | O20250110000603 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003660036 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Gina Lawrence |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1235545443 PECOS PAC ID: 3678916566 Enrollment ID: I20240207003588 |
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