MEDICARE: BEACH LIFE COUNSELING & CONSULTING SERVICES, PLLC

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	101YP2500X	Professional Counselor	6608-125	WI
2	101YP2500X	Professional Counselor	0701004811	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1376793083	OTHER		NPI - TYPE 1

General Provider Information

NPI Number	:	1114438702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACH LIFE COUNSELING & CONSULTING SERVICES, PLLC

Provider Business Mailing Address
First Line	:	576 N BIRDNECK RD STE 631
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6374
Country	:	US
Telephone Number	:	757-837-2483
Fax Number	:

Provider Business Practice Location Address
First Line	:	576 N BIRDNECK RD STE 631
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6374
Country	:	US
Telephone Number	:	757-837-2483
Fax Number	:

Authorized Official
Title or Position	:	OWNER - PRIVATE PRACTICE COUNSELING
Name	:	JAYNE CARRELS-ZELLER
Credential	:	MS, LPC, NCC
Telephone Number	:	757-837-2483

Provider Enumeration Date	:	10/23/2017
Last Update Date	:	10/23/2017

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