MEDICARE: QUALITY OF LIFE COUNSELING CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1033516448
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALITY OF LIFE COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	1 ENTERPRISE PKWY STE 315
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-5845
Country	:	US
Telephone Number	:	757-998-2100
Fax Number	:	757-998-2101

Provider Business Practice Location Address
First Line	:	1 ENTERPRISE PKWY STE 315
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-5845
Country	:	US
Telephone Number	:	757-998-2100
Fax Number	:	757-998-2101

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. DEUENE HICKMAN III
Credential	:
Telephone Number	:	910-263-1887

Provider Enumeration Date	:	12/01/2014
Last Update Date	:	05/03/2024

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