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General NPI Number Information
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NPI Number | 1699705459
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Entity Type | Organization
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Legal Business Name | TREE OF LIFE CHRISTIAN COUNSELING AGENCY, LLC
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 4936 SOUTHPOINT PKWY
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City | FREDERICKSBURG
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State | VA
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Zip | 22407-2659
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Country | US
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Telephone | 540-710-0520
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Fax | 703-490-3544
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Provider Business Mailing Address
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Address Line | PO BOX 42111
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City | FREDERICKSBURG
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State | VA
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Zip | 22404-2111
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Country | US
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Telephone | 540-710-0520
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Fax | 703-490-3544
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. PHILICIA JEFFERSON
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Credential | PH.D
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Telephone | 540-710-0520
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 831
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License Number State | VA
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