MEDICARE: THE TREE OF LIFE COUNSELING CENTER

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1750985701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE TREE OF LIFE COUNSELING CENTER

Provider Business Mailing Address
First Line	:	2402 S MIAMI BLVD STE 108
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27703-4928
Country	:	US
Telephone Number	:	919-696-0072
Fax Number	:

Provider Business Practice Location Address
First Line	:	2402 S MIAMI BLVD STE 108
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27703-4928
Country	:	US
Telephone Number	:	919-696-0072
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	TATISHA FAUNTLEROY
Credential	:	LPC
Telephone Number	:	919-696-0072

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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