Healthcare Provider Details

I. General information

NPI: 1407467434
Provider Name (Legal Business Name): LIFE CHANGES COUNSELING AND CONSULTANT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 VIRGINIA AVE STE 104
ATLANTA GA
30354-1366
US

IV. Provider business mailing address

1003 VIRGINIA AVE STE 104
ATLANTA GA
30354-1366
US

V. Phone/Fax

Practice location:
  • Phone: 404-500-1994
  • Fax:
Mailing address:
  • Phone: 404-500-1994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TERENCE WILKINS
Title or Position: CEO
Credential: LPC, MAC
Phone: 609-743-1773