Healthcare Provider Details

I. General information

NPI: 1316650062
Provider Name (Legal Business Name): LIFESTYLE CHANGES AND CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2252 TOWER DR STE 108
MONROE LA
71201-5765
US

IV. Provider business mailing address

2252 TOWER DR STE 108
MONROE LA
71201-5765
US

V. Phone/Fax

Practice location:
  • Phone: 318-805-2992
  • Fax:
Mailing address:
  • Phone: 318-805-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MISHEMA BOLEY
Title or Position: LPC
Credential: LPC-S
Phone: 318-805-2992