Healthcare Provider Details

I. General information

NPI: 1487102331
Provider Name (Legal Business Name): LIFESTYLE CHANGES COUNSELING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 GOODING ST N
TWIN FALLS ID
83301-6178
US

IV. Provider business mailing address

219 GOODING ST N
TWIN FALLS ID
83301-6178
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-5230
  • Fax: 208-732-5894
Mailing address:
  • Phone: 208-734-5230
  • Fax: 208-732-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: WILLIAM L VIRTUE
Title or Position: PRESIDENT
Credential:
Phone: 208-316-5436