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General NPI Number Information
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NPI Number | 1336166040
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Entity Type | Organization
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Legal Business Name | LIFELINE COUNSELING CENTER LLC
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 10/09/2011
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Provider Practice Location Address
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Address Line | 4212 STATE ROUTE 306 SUITE 306
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City | WILLOUGHBY
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State | OH
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Zip | 44094-9258
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Country | US
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Telephone | 440-942-0100
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Fax | 877-581-3908
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Provider Business Mailing Address
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Address Line | 4212 STATE ROUTE 306 SUITE 306
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City | WILLOUGHBY
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State | OH
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Zip | 44094-9258
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Country | US
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Telephone | 440-942-0100
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Fax | 877-581-3908
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. JAMES WILSON DAVIDSON
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Credential | PH.D.
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Telephone | 440-942-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2071
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License Number State | OH
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