Healthcare Provider Details

I. General information

NPI: 1003214891
Provider Name (Legal Business Name): LIVIN' THE LIGHT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MERCANTILE LN SUITE 208
LARGO MD
20774-5341
US

IV. Provider business mailing address

1400 MERCANTILE LN SUITE 208
LARGO MD
20774-5341
US

V. Phone/Fax

Practice location:
  • Phone: 301-627-4777
  • Fax: 301-627-8939
Mailing address:
  • Phone: 301-627-4777
  • Fax: 301-627-8939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC0903
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLC0903
License Number StateMD

VIII. Authorized Official

Name: MS. CHRISTINE D WILLIAMS
Title or Position: DIRECTOR
Credential: LCPC
Phone: 301-627-4777