MEDICARE: LIFE RESTORATION COUNSELING & PSYCHOLOGICAL SERVICES

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	251S00000X	Community/Behavioral Health Agency	6301009751	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103T00000X	OTHER		TAXONOMY
2	1992124390	OTHER	MI	NPI

General Provider Information

NPI Number	:	1558879270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE RESTORATION COUNSELING & PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	6489 SHORELINE DR
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48085-1048
Country	:	US
Telephone Number	:	248-709-3897
Fax Number	:	248-828-6364

Provider Business Practice Location Address
First Line	:	525 E BIG BEAVER RD STE 201
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48083-1363
Country	:	US
Telephone Number	:	248-709-3897
Fax Number	:	248-828-6364

Authorized Official
Title or Position	:	BILLING CEO
Name	:	SHELLEY A TAGLIONE
Credential	:
Telephone Number	:	734-414-0754

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	01/16/2018

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