MEDICARE: SUCCESSFUL LIFE COACHING AND COUNSELING SERVICES, 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	101Y00000X	Counselor
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1871442673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESSFUL LIFE COACHING AND COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	11510 PEGASUS CT
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-7823
Country	:	US
Telephone Number	:	240-221-1617
Fax Number	:

Provider Business Practice Location Address
First Line	:	11510 PEGASUS CT
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-7823
Country	:	US
Telephone Number	:	240-221-1617
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STACI C BURROUGH
Credential	:	MA, LCPC, LAPC
Telephone Number	:	240-221-1617

Provider Enumeration Date	:	01/26/2026
Last Update Date	:	01/26/2026

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