MEDICARE: ONE LIFE YOUTH AND FAMILY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor
3	1041C0700X	Clinical Social Worker
4	251S00000X	Community/Behavioral Health Agency
5	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1992122113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE LIFE YOUTH AND FAMILY SERVICES LLC

Provider Business Mailing Address
First Line	:	7303 SHIRAS CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-9606
Country	:	US
Telephone Number	:	980-333-7411
Fax Number	:

Provider Business Practice Location Address
First Line	:	2676 W MAIN ST
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-8910
Country	:	US
Telephone Number	:	704-345-2032
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. WAYNE LEVONNE BURCH SR.
Credential	:
Telephone Number	:	704-345-2032

Provider Enumeration Date	:	03/26/2014
Last Update Date	:	12/01/2014

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Directions to “ONE LIFE YOUTH AND FAMILY SERVICES LLC ” Practice Location

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