Provider Demographics
NPI:1376037366
Name:LIFESTYLE INNOVATIONS COUNSELING AND CONSULTING INC
Entity Type:Organization
Organization Name:LIFESTYLE INNOVATIONS COUNSELING AND CONSULTING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREANA
Authorized Official - Middle Name:
Authorized Official - Last Name:YANCEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:202-627-9892
Mailing Address - Street 1:15912 CRAIN HWY STE B125
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-8035
Mailing Address - Country:US
Mailing Address - Phone:202-627-9892
Mailing Address - Fax:
Practice Address - Street 1:15912 CRAIN HWY STE B125
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-8035
Practice Address - Country:US
Practice Address - Phone:202-627-9892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD221208100Medicaid