MEDICARE: LIFE COACH PSYCHOLOGY

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	103TC1900X	Counseling Psychologist	6301010743	MI

General Provider Information

NPI Number	:	1245543370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE COACH PSYCHOLOGY

Provider Business Mailing Address
First Line	:	9067 US HIGHWAY 31
Second Line	:	SUITE 203
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-1664
Country	:	US
Telephone Number	:	269-471-9892
Fax Number	:

Provider Business Practice Location Address
First Line	:	9067 US HIGHWAY 31
Second Line	:	SUITE 203
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-1664
Country	:	US
Telephone Number	:	269-471-9892
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HAROLD SMITH
Credential	:	M.D.
Telephone Number	:	269-471-9892

Provider Enumeration Date	:	07/19/2010
Last Update Date	:	07/19/2010

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