Provider Demographics
NPI:1114438702
Name:BEACH LIFE COUNSELING & CONSULTING SERVICES, PLLC
Entity Type:Organization
Organization Name:BEACH LIFE COUNSELING & CONSULTING SERVICES, PLLC
Other - Org Name:BEACH LIFE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER - PRIVATE PRACTICE COUNSELING
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRELS-ZELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, NCC
Authorized Official - Phone:757-837-2483
Mailing Address - Street 1:576 N BIRDNECK RD STE 631
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6374
Mailing Address - Country:US
Mailing Address - Phone:757-837-2483
Mailing Address - Fax:
Practice Address - Street 1:576 N BIRDNECK RD STE 631
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6374
Practice Address - Country:US
Practice Address - Phone:757-837-2483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004811101YP2500X
WI6608-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376793083OtherNPI - TYPE 1