MEDICARE: CHRISTIAN LIFE COUNSELING LLC

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	1041C0700X	Clinical Social Worker
3	106H00000X	Marriage & Family Therapist
4	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1659466860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTIAN LIFE COUNSELING LLC

Provider Business Mailing Address
First Line	:	12630 W NORTH AVE BLDG E
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-4626
Country	:	US
Telephone Number	:	262-785-1008
Fax Number	:	262-462-3187

Provider Business Practice Location Address
First Line	:	12630 W NORTH AVE BLDG E
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53005-4626
Country	:	US
Telephone Number	:	262-785-1008
Fax Number	:	262-462-3187

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JENNIFER MENGO
Credential	:
Telephone Number	:	262-785-1008

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	04/26/2018

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Directions to “CHRISTIAN LIFE COUNSELING LLC ” Practice Location

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