Healthcare Provider Details

I. General information

NPI: 1912137050
Provider Name (Legal Business Name): LIFE CHANGING BEHAVIRAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S MAIN ST
FAIRMONT NC
28340-1906
US

IV. Provider business mailing address

314 S MAIN ST
FAIRMONT NC
28340-1906
US

V. Phone/Fax

Practice location:
  • Phone: 910-628-9091
  • Fax: 910-628-9093
Mailing address:
  • Phone: 910-628-9091
  • Fax: 910-628-9093

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 Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LUIS ROMAN
Title or Position: COO
Credential:
Phone: 910-770-2682