Healthcare Provider Details

I. General information

NPI: 1205213527
Provider Name (Legal Business Name): DIVERSIFIED LIFESTYLE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 I ST NW SUITE 400E
WASHINGTON DC
20005-3314
US

IV. Provider business mailing address

137 NATIONAL PLZ SUITE 300
OXON HILL MD
20745-1152
US

V. Phone/Fax

Practice location:
  • Phone: 301-804-8279
  • Fax:
Mailing address:
  • Phone: 240-273-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPRC14152
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACII1131
License Number StateDC

VIII. Authorized Official

Name: DR. ANTOINETTE LANCASTER
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC, LCPC, NCC, MAC
Phone: 202-239-5563