NPIMap

Organization Active NPI

Lifespan Psychology Services, LLC

  • Psychologist
  • Tampa, FL
National Provider Identifier
1770844433
Registry record updated May 30, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
PsychologistTaxonomy code 103T00000X
Legal business name
LIFESPAN PSYCHOLOGY SERVICES, LLC
Practice address
4201 Bayshore Blvd
Unit 1603
Tampa, FL 33611-1669
Phone
(617) 784-0771
NPI assigned
May 30, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 30, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Athena Boolukos Gordon, ED.M., PSY.D.NPI 1700146552
Title
President
Phone
(617) 784-0771

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X Primary

Addresses

Primary practice location

4201 Bayshore Blvd
Unit 1603
Tampa, FL 33611-1669

Mailing address

4201 Bayshore Blvd
Unit 1603
Tampa, FL 33611-1669
Phone (617) 784-0771

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1338336000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1338336000000",
    "number": "1770844433",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4201 BAYSHORE BLVD",
            "address_2": "UNIT 1603",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336111669",
            "telephone_number": "617-784-0771"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4201 BAYSHORE BLVD",
            "address_2": "UNIT 1603",
            "city": "TAMPA",
            "state": "FL",
            "postal_code": "336111669",
            "telephone_number": "617-784-0771"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFESPAN PSYCHOLOGY SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-05-30",
        "last_updated": "2012-05-30",
        "status": "A",
        "authorized_official_last_name": "GORDON",
        "authorized_official_first_name": "ATHENA",
        "authorized_official_middle_name": "BOOLUKOS",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "617-784-0771",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "ED.M., PSY.D."
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tampa, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 30, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.