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General NPI Number Information
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NPI Number | 1619841038
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Entity Type | Organization
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Legal Business Name | AUTHENTIC LIVING LAB LLC
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Dates
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Enumeration Date | 09/30/2025
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Last Update Date | 09/30/2025
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Provider Practice Location Address
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Address Line | 220 OLDE SPRINGS RD
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City | COLUMBIA
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State | SC
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Zip | 29223-1612
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Country | US
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Telephone | 803-714-3774
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Fax |
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Provider Business Mailing Address
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Address Line | 9600 TWO NOTCH RD SUITE 5 # 1285
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City | COLUMBIA
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State | SC
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Zip | 29223-1612
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Country | US
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Telephone | 803-714-3774
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MISS DELSONDRA JONELL ALLEN
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Credential | LISW- CP
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Telephone | 803-714-3774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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