Provider Demographics
NPI:1417148420
Name:LIFECHANGES FAMILY GUIDANCE & WELLNESS INC.
Entity Type:Organization
Organization Name:LIFECHANGES FAMILY GUIDANCE & WELLNESS INC.
Other - Org Name:OPEN DOORS COUNSELING & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRINA
Authorized Official - Middle Name:DEVONNE
Authorized Official - Last Name:WINFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LPCS
Authorized Official - Phone:336-577-6652
Mailing Address - Street 1:1922 S MARTIN LUTHER KING JR DR # 74
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1361
Mailing Address - Country:US
Mailing Address - Phone:336-464-1322
Mailing Address - Fax:888-320-8093
Practice Address - Street 1:1922 MLK JR. DRIVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-1361
Practice Address - Country:US
Practice Address - Phone:336-776-3154
Practice Address - Fax:336-464-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 251E00000X, 251S00000X, 253Z00000X
SC251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8090Medicaid