Healthcare Provider Details

I. General information

NPI: 1720391295
Provider Name (Legal Business Name): LIFE CENTERS USA COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 CENTRAL AVE
COLONIE NY
12205-5065
US

IV. Provider business mailing address

19 WILBUR ST
COLONIE NY
12205-4555
US

V. Phone/Fax

Practice location:
  • Phone: 518-669-6133
  • Fax: 518-869-2122
Mailing address:
  • Phone: 518-669-6133
  • Fax: 518-869-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19061
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. DEBRA A HENDRON
Title or Position: OWNER
Credential: PHD
Phone: 518-669-6133