Healthcare Provider Details

I. General information

NPI: 1477195154
Provider Name (Legal Business Name): THE LIFE SOURCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3228 UNIVERSITY AVE STE 103
COLUMBUS GA
31907-7201
US

IV. Provider business mailing address

3228 UNIVERSITY AVE STE 103
COLUMBUS GA
31907-7201
US

V. Phone/Fax

Practice location:
  • Phone: 762-207-8218
  • Fax: 706-400-6478
Mailing address:
  • Phone: 762-207-8218
  • Fax: 706-400-6478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LATEASHA SKINNER
Title or Position: CEO
Credential: LPC
Phone: 762-207-8218