Provider Demographics
NPI:1477186278
Name:LIFE SUPPORT CLINICAL COUNSELING SERVICE LLC/PRP
Entity Type:Organization
Organization Name:LIFE SUPPORT CLINICAL COUNSELING SERVICE LLC/PRP
Other - Org Name:LIFE SUPPORT CLINICAL COUNSELING SERVICE LLC/PRP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:RITA
Authorized Official - Last Name:HUNLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-980-3163
Mailing Address - Street 1:825 JANET DALE LN
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-2789
Mailing Address - Country:US
Mailing Address - Phone:410-980-3163
Mailing Address - Fax:410-969-2958
Practice Address - Street 1:1412 CRAIN HWY N STE 6B
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-9306
Practice Address - Country:US
Practice Address - Phone:410-980-3163
Practice Address - Fax:410-969-2958
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE SUPPORT CLINICAL COUNSELING SERVICE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH-540-048-738-351OtherDRIVER LICENSE