=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346966272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYFE SKILLS COLLABORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 PRAIRIE ST
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71295-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-367-5099
-----------------------------------------------------
Fax | 318-367-5090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 PRAIRIE ST
-----------------------------------------------------
City | WINNSBORO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71295-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-367-5099
-----------------------------------------------------
Fax | 318-367-5090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ROCHELLE KELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-547-6293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------