Healthcare Provider Details

I. General information

NPI: 1558184325
Provider Name (Legal Business Name): PURE LIFE COUNSELING AND TESTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 RIGBY ST
MARION VA
24354-6342
US

IV. Provider business mailing address

PO BOX 1791
MARION VA
24354-8689
US

V. Phone/Fax

Practice location:
  • Phone: 276-206-3040
  • Fax: 540-527-9810
Mailing address:
  • Phone: 276-206-3040
  • Fax: 540-527-9810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SHELBY COOK MITCHELL
Title or Position: OWNEER
Credential: LPC
Phone: 276-206-3040