MEDICARE: LIFE KINGDOM OUTREACH MINISTRIES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	106H00000X	Marriage & Family Therapist
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1407621998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE KINGDOM OUTREACH MINISTRIES, INC.

Provider Business Mailing Address
First Line	:	1570 CHAPEL ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-4251
Country	:	US
Telephone Number	:	203-999-8734
Fax Number	:

Provider Business Practice Location Address
First Line	:	1570 CHAPEL ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-4251
Country	:	US
Telephone Number	:	203-999-8734
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. GERALDINE HANDY-MORRIS
Credential	:
Telephone Number	:	203-999-8734

Provider Enumeration Date	:	11/15/2023
Last Update Date	:	11/15/2023

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