=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639489149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITH IN LIFE COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2010
-----------------------------------------------------
Last Update Date | 10/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3663 E SUNSET RD STE 104
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-496-6054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3663 E. SUNSET RD. STE. 104
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-496-6054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MS. TAMARA SUE MCMANIGELL
-----------------------------------------------------
Credential | MSEDCPC
-----------------------------------------------------
Telephone | 702-496-6054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | CP0028
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------