=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821628199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESTYLE OVERHAUL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2020
-----------------------------------------------------
Last Update Date | 04/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 98 E LAKE MEAD PKWY STE 201
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89015-6443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-433-3038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 98 E LAKE MEAD PKWY STE 201
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89015-6443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-433-3038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROFESSIONAL CLINICAL COUNSELOR
-----------------------------------------------------
Name | MRS. CLAUDIA JOHNSON
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 708-752-3361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------