Healthcare Provider Details

I. General information

NPI: 1356539795
Provider Name (Legal Business Name): LIFE CHANGERS INTERVENTION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5039 MAIN ST SUITE 2
SHALLOTTE NC
28470
US

IV. Provider business mailing address

5039 MAIN ST SUITE 2
SHALLOTTE NC
28470
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-7988
  • Fax:
Mailing address:
  • Phone: 910-754-7988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. BEVERLY STANLEY
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential:
Phone: 910-754-7988