MEDICARE: LIFESSENTIALS COUNSELING, 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	0675	OH

General Provider Information

NPI Number	:	1134455827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESSENTIALS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	131 N LUDLOW ST
Second Line	:	SUITE 1212
City	:	DAYTON
State	:	OH
Zip	:	45402-1116
Country	:	US
Telephone Number	:	937-222-5496
Fax Number	:	937-222-5497

Provider Business Practice Location Address
First Line	:	131 N LUDLOW ST
Second Line	:	SUITE 1212
City	:	DAYTON
State	:	OH
Zip	:	45402-1116
Country	:	US
Telephone Number	:	937-222-5496
Fax Number	:	937-222-5497

Authorized Official
Title or Position	:	ADMINISTRATOR/CREDENTIALING
Name	:	MRS. NETTIE L PUTNAM
Credential	:
Telephone Number	:	937-222-5496

Provider Enumeration Date	:	10/30/2009
Last Update Date	:	09/08/2011

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