=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740525930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE STRATEGY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2012
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1949 SUGARLAND DR SUITE 218
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-674-8686
-----------------------------------------------------
Fax | 307-674-1825
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1949 SUGARLAND DR SUITE 218
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-674-8686
-----------------------------------------------------
Fax | 307-674-1825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MGR/LICENSEDPROFESSIONALCOUNS
-----------------------------------------------------
Name | MR. CHARLES DEAN SHIPLEY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 307-674-8686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 1316
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------