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General NPI Number Information
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NPI Number | 1699551507
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Entity Type | Organization
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Legal Business Name | LEAVE YOUR MARK LIFE COACHING
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Dates
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Enumeration Date | 09/06/2023
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 762 INDEPENDENCE BLVD STE 786
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-6200
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Country | US
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Telephone | 757-493-1514
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Fax |
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Provider Business Mailing Address
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Address Line | 762 INDEPENDENCE BLVD STE 786
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-6200
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Country | US
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Telephone | 757-493-1514
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Fax |
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Authorized Official
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Title or Position | LMFT/OWNER
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Name | NICKOLAS NICHOLS
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Credential | LMFT
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Telephone | 757-493-1514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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