MEDICARE: LIFE FOUNDATIONS WELLNESS AND SUPPORTIVE COUNSELING SERVICES, 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	101Y00000X	Counselor	1622	NC
2	101YM0800X	Mental Health Counselor	1622	NC
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	1622	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396042164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE FOUNDATIONS WELLNESS AND SUPPORTIVE COUNSELING SERVICES, LLC.

Provider Business Mailing Address
First Line	:	1910 SEDWICK RD BLDG 400
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-7807
Country	:	US
Telephone Number	:	919-949-8539
Fax Number	:	919-949-8539

Provider Business Practice Location Address
First Line	:	1910 SEDWICK RD BLDG 400
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-7807
Country	:	US
Telephone Number	:	919-949-8539
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DIETRIX URQUHART
Credential	:
Telephone Number	:	919-949-8539

Provider Enumeration Date	:	02/14/2011
Last Update Date	:	06/04/2012

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