Provider Demographics
NPI:1497047237
Name:LGBT LIFE CENTER
Entity Type:Organization
Organization Name:LGBT LIFE CENTER
Other - Org Name:CANDII
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-907-2567
Mailing Address - Street 1:222 W 21ST ST # F-308
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2200
Mailing Address - Country:US
Mailing Address - Phone:757-907-2567
Mailing Address - Fax:757-578-2863
Practice Address - Street 1:222 W 21ST ST # F-308
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2200
Practice Address - Country:US
Practice Address - Phone:757-640-0929
Practice Address - Fax:757-622-8932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0087422272Medicaid
VA1497047237Medicaid