Provider Demographics
NPI:1548786478
Name:LIFETRACK COUNSELING LLC
Entity Type:Organization
Organization Name:LIFETRACK COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WICHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, LCDC
Authorized Official - Phone:972-977-0203
Mailing Address - Street 1:904 GRANGER DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-1102
Mailing Address - Country:US
Mailing Address - Phone:972-977-0203
Mailing Address - Fax:
Practice Address - Street 1:904 GRANGER DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-1102
Practice Address - Country:US
Practice Address - Phone:972-977-0203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX70313251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty