MEDICARE: TREE OF LIFE COUNSELING, PLLC

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
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YP2500X	Professional Counselor	7308	NC
4	1041C0700X	Clinical Social Worker
5	106H00000X	Marriage & Family Therapist
6	261QM1300X	Multi-Specialty Clinic/Center
7	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S7803	OTHER	NC	NORTH CAROLINA BOARD OF LICENSED CLINICAL MENTAL HEALTH COUNSELORS

General Provider Information

NPI Number	:	1477819712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREE OF LIFE COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	5 OAK BRANCH DR STE H
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-2157
Country	:	US
Telephone Number	:	336-288-9190
Fax Number	:	336-450-4318

Provider Business Practice Location Address
First Line	:	5 OAK BRANCH DR STE H
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-2157
Country	:	US
Telephone Number	:	336-288-9190
Fax Number	:	336-450-4318

Authorized Official
Title or Position	:	OWNER
Name	:	SHANA GORDON WALTMAN
Credential	:	MA
Telephone Number	:	336-288-9190

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	08/26/2025

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Directions to “TREE OF LIFE COUNSELING, PLLC ” Practice Location

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