Healthcare Provider Details

I. General information

NPI: 1962972117
Provider Name (Legal Business Name): WILLIFORD WELLNESS COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 TRAVIS ST STE 214
LAFAYETTE LA
70503-2432
US

IV. Provider business mailing address

114 RANGE DR
LAFAYETTE LA
70508-1728
US

V. Phone/Fax

Practice location:
  • Phone: 337-541-0117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. AIMEE P WILLIFORD
Title or Position: OWNER
Credential: LPC
Phone: 337-541-0117