MEDICARE: TREE OF LIFE COUNSELING & CONSULTING, 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	1041C0700X	Clinical Social Worker	4510C	AR

General Provider Information

NPI Number	:	1356874945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREE OF LIFE COUNSELING & CONSULTING, LLC

Provider Business Mailing Address
First Line	:	422 COUNTY ROAD 225
Second Line	:
City	:	CHERRY VALLEY
State	:	AR
Zip	:	72324-8760
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	713 FALLS BLVD N
Second Line	:	SUITE A
City	:	WYNNE
State	:	AR
Zip	:	72396-2208
Country	:	US
Telephone Number	:	870-587-7056
Fax Number	:

Authorized Official
Title or Position	:	INCORPORATOR/ORGANIZER
Name	:	MRS. MERIDETH L JOHNSON
Credential	:	LCSW
Telephone Number	:	870-587-7056

Provider Enumeration Date	:	04/10/2017
Last Update Date	:	04/10/2017

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