Provider Demographics
NPI:1407478555
Name:ABUNDANT LIFE COUNSELING & CONSULTING SERVICES, LLC
Entity Type:Organization
Organization Name:ABUNDANT LIFE COUNSELING & CONSULTING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NYCOLA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOUCK
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:419-359-0307
Mailing Address - Street 1:348 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1610
Mailing Address - Country:US
Mailing Address - Phone:419-359-0307
Mailing Address - Fax:833-667-6490
Practice Address - Street 1:348 MAIN ST
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:OH
Practice Address - Zip Code:44839-1610
Practice Address - Country:US
Practice Address - Phone:419-359-0307
Practice Address - Fax:833-667-6490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1700431277OtherNPPES
OH1619188463OtherNPPES