Healthcare Provider Details

I. General information

NPI: 1154819472
Provider Name (Legal Business Name): CHOOSE LIFE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 N CRUTCHFIELD ST
DOBSON NC
27017-8804
US

IV. Provider business mailing address

187 JENNA WOODS TRL
MOUNT AIRY NC
27030-8557
US

V. Phone/Fax

Practice location:
  • Phone: 336-926-2293
  • Fax: 336-352-3635
Mailing address:
  • Phone: 336-926-2293
  • Fax: 336-352-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3310
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10435
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. JOHN SINK PULLIAM JR.
Title or Position: DIRECTOR
Credential: LPC, LCAS, CCS
Phone: 336-926-2293