=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417534306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2021
-----------------------------------------------------
Last Update Date | 03/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 JOHN ST STE B
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-317-7776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 GRACE WAY
-----------------------------------------------------
City | ELKINS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26241-1194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-614-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JIM WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-317-7776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------