Healthcare Provider Details

I. General information

NPI: 1639395858
Provider Name (Legal Business Name): LIFE ARTS COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 MARKET ST STE 2 DOWNTOWN RIVERSIDE
RIVERSIDE CA
92501-3515
US

IV. Provider business mailing address

PO BOX 1145
RIVERSIDE CA
92502-1145
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6322
  • Fax: 951-683-6900
Mailing address:
  • Phone: 951-683-6322
  • Fax: 951-683-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC25858
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMFC25858
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberMFC25858
License Number StateCA

VIII. Authorized Official

Name: VERA STAMENKOVIC
Title or Position: MFCC
Credential: M.S.
Phone: 951-683-6322