Healthcare Provider Details

I. General information

NPI: 1285239228
Provider Name (Legal Business Name): LIFE'S JOURNEY COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MAIN ST
GRISWOLD CT
06351-2226
US

IV. Provider business mailing address

PO BOX 296
ROGERS CT
06263-0296
US

V. Phone/Fax

Practice location:
  • Phone: 860-634-0967
  • Fax:
Mailing address:
  • Phone: 860-634-0967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS GAUGHAN
Title or Position: OWNER
Credential: LPC/LADC
Phone: 860-634-0967