Healthcare Provider Details

I. General information

NPI: 1801606462
Provider Name (Legal Business Name): THE LIFE SOURCE GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 WYNNTON RD STE A
COLUMBUS GA
31906-5718
US

IV. Provider business mailing address

1425 WYNNTON RD STE A
COLUMBUS GA
31906-5718
US

V. Phone/Fax

Practice location:
  • Phone: 706-984-0215
  • Fax:
Mailing address:
  • Phone: 334-984-0215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. LATEASHA SKINNER
Title or Position: OWNER
Credential: LPC
Phone: 706-984-0215