=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164882759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CYCLE OF LIFE COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2016
-----------------------------------------------------
Last Update Date | 11/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15720 BRIXHAM HILL AVE STE 300
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-4784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-412-8360
-----------------------------------------------------
Fax | 704-603-3006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15720 BRIXHAM HILL AVE STE 300
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-4784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-412-8360
-----------------------------------------------------
Fax | 704-603-3006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | LISA M DEVORE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 704-412-8360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------