Healthcare Provider Details

I. General information

NPI: 1205473329
Provider Name (Legal Business Name): LIFE ENHANCED COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 12/09/2019
Certification Date: 12/09/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5330 W VILLARD AVE
MILWAUKEE WI
53218-4345
US

IV. Provider business mailing address

1711 W CLAYTON CREST AVE
MILWAUKEE WI
53221-3830
US

V. Phone/Fax

Practice location:
  • Phone: 414-690-0672
  • Fax:
Mailing address:
  • Phone: 414-690-0672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TONYETTA L ROSS
Title or Position: DIRECTOR
Credential: LPC, CSAC, ICAADC,
Phone: 414-690-0672