MEDICARE: LIFESTYLE MANAGEMENT COUNSELING CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CSW004714	GA

General Provider Information

NPI Number	:	1376894816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE MANAGEMENT COUNSELING CENTER, LLC

Provider Business Mailing Address
First Line	:	2404 HUBBARD ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2911
Country	:	US
Telephone Number	:	904-902-2454
Fax Number	:	888-474-2998

Provider Business Practice Location Address
First Line	:	2404 HUBBARD ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2911
Country	:	US
Telephone Number	:	904-902-2454
Fax Number	:	888-474-2998

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. STEPHANIE MCELVEEN
Credential	:	LCSW
Telephone Number	:	904-902-2454

Provider Enumeration Date	:	09/24/2012
Last Update Date	:	10/22/2024

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