Provider Demographics
NPI:1376847970
Name:LDH AMBASSADDORS FOR LIFE FAITH BASE COUNSELING SERVICES
Entity Type:Organization
Organization Name:LDH AMBASSADDORS FOR LIFE FAITH BASE COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NCCA, LCPC
Authorized Official - Phone:440-728-0287
Mailing Address - Street 1:33896 SUNFLOWER LANE
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039
Mailing Address - Country:US
Mailing Address - Phone:440-728-0287
Mailing Address - Fax:
Practice Address - Street 1:33896 SUNFLOWER LANE
Practice Address - Street 2:
Practice Address - City:NORTH RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039
Practice Address - Country:US
Practice Address - Phone:440-728-0287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12671101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty