MEDICARE: LITHOS COUNSELING AND 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1568014736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITHOS COUNSELING AND CONSULTING, LLC

Provider Business Mailing Address
First Line	:	1805 GREEN CIR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2734
Country	:	US
Telephone Number	:	229-415-7621
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 GREEN CIR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-2734
Country	:	US
Telephone Number	:	229-415-7621
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRADFORD COLEMAN
Credential	:
Telephone Number	:	404-287-8103

Provider Enumeration Date	:	07/09/2019
Last Update Date	:	07/09/2019

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