Provider Demographics
NPI:1407263601
Name:NEW LIFE COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:NEW LIFE COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:LASHAN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPCC
Authorized Official - Phone:859-368-3160
Mailing Address - Street 1:585 SOUTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5121
Mailing Address - Country:US
Mailing Address - Phone:859-368-3160
Mailing Address - Fax:859-406-1066
Practice Address - Street 1:1099 S BROADWAY
Practice Address - Street 2:STE. 260, 160, AND 280
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2663
Practice Address - Country:US
Practice Address - Phone:859-309-2384
Practice Address - Fax:859-406-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-20
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1444101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100266640Medicaid