Healthcare Provider Details

I. General information

NPI: 1164312179
Provider Name (Legal Business Name): THIRD LIFE CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LAPALCO BLVD STE H
GRETNA LA
70056-7372
US

IV. Provider business mailing address

400 LAPALCO BLVD STE H
GRETNA LA
70056-7372
US

V. Phone/Fax

Practice location:
  • Phone: 504-224-0903
  • Fax:
Mailing address:
  • Phone: 504-224-0903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DEMETRIUS RAYFORD
Title or Position: PRINCIPAL CONSULTANT
Credential: RCP
Phone: 504-224-0903