Healthcare Provider Details

I. General information

NPI: 1821628199
Provider Name (Legal Business Name): LIFESTYLE OVERHAUL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 E LAKE MEAD PKWY STE 201
HENDERSON NV
89015-6443
US

IV. Provider business mailing address

98 E LAKE MEAD PKWY STE 201
HENDERSON NV
89015-6443
US

V. Phone/Fax

Practice location:
  • Phone: 702-433-3038
  • Fax:
Mailing address:
  • Phone: 702-433-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. CLAUDIA JOHNSON
Title or Position: PROFESSIONAL CLINICAL COUNSELOR
Credential: LCPC
Phone: 708-752-3361