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General NPI Number Information
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NPI Number | 1568918415
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Entity Type | Organization
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Legal Business Name | LIFE ADVANCEMENT SERVICES PLLC
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Dates
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Enumeration Date | 08/31/2016
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Last Update Date | 08/31/2016
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Provider Practice Location Address
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Address Line | 1332 CUSHING ST 1108 GRACADE STREET
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City | GREENSBORO
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State | NC
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Zip | 27405-3322
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Country | US
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Telephone | 336-383-9932
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Fax |
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Provider Business Mailing Address
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Address Line | 1332 CUSHING STREET 1108 GRACADE STREET
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City | GREENSBORO
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State | NC
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Zip | 27408
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Country | US
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Telephone | 336-383-9932
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NETTIE ROSE CLARKE
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Credential | MS, LPC, LCAS-A,
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Telephone | 336-383-9932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 10171
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License Number State | NC
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