Provider Demographics
NPI:1396042164
Name:LIFE FOUNDATIONS WELLNESS AND SUPPORTIVE COUNSELING SERVICES, LLC.
Entity Type:Organization
Organization Name:LIFE FOUNDATIONS WELLNESS AND SUPPORTIVE COUNSELING SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DIETRIX
Authorized Official - Middle Name:
Authorized Official - Last Name:URQUHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-949-8539
Mailing Address - Street 1:1910 SEDWICK RD BLDG 400
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7807
Mailing Address - Country:US
Mailing Address - Phone:919-949-8539
Mailing Address - Fax:919-949-8539
Practice Address - Street 1:1910 SEDWICK RD BLDG 400
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7807
Practice Address - Country:US
Practice Address - Phone:919-949-8539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1622101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008457Medicaid