Healthcare Provider Details

I. General information

NPI: 1912409681
Provider Name (Legal Business Name): LIFE BALANCE COUNSELING AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 CHARTRES ST
LA SALLE IL
61301-1107
US

IV. Provider business mailing address

418 OAK ST
SPRING VALLEY IL
61362-2327
US

V. Phone/Fax

Practice location:
  • Phone: 309-830-1096
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE STODDARD
Title or Position: PRESIDENT
Credential: LCPC
Phone: 309-830-1096