Healthcare Provider Details

I. General information

NPI: 1679791677
Provider Name (Legal Business Name): LIFE SUPPORT COUNSELING AND RESEARCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 S 2ND ST STE C400
AUSTIN TX
78704-7059
US

IV. Provider business mailing address

3809 S 2ND ST STE C400
AUSTIN TX
78704-7059
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-7310
  • Fax: 512-451-0394
Mailing address:
  • Phone: 512-451-7310
  • Fax: 512-451-0394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: LEON SMITH
Title or Position: EXECUTIVE DIRECTOR
Credential: LPC, LSOTP
Phone: 512-451-7310